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Wednesday, 13 October 1971
Page: 2273

Dr GUN (Kingston) - First, I wish to protest at the haste with which this legislation is being pushed through the House. This Bill with which we are dealing embodies 3 extremely important measures. W.e are dealing with an increase in the nursing home subsidy and the doubling of the prescription charge. We are enacting also in this legislation an increase in the fees of general practitioners. It would seem to me that any one of these measures could command a full day's discussion of this House. It seems to me also an exercise in indecent haste to push the Bill through in one day. Perhaps it is not a coincidence that this is the one day in the sitting week on which the proceedings of the House are not being broadcast. The first matter with which I wish to deal has to do with nursing homes. The Bill proposes to increase the level of nursing home payments made by this Government. Because this provision is included in the Bill, we propose to support the Bill at its second and third reading stages although we have moved an amendment at the second reading stage.

The cost of nursing home care is perhaps the most serious problem in the whole structure of community welfare services. The problem is entirely of the Government's own making and is due to the failure of the Government to formulate any programme of care for the chronically ill. All the Government's attention has been focussed on the acute hospitals, and what happens to patients outside the acute hospitals has been regarded by this Government as someone else's problem.

The matter of nursing home care must be integrated on the one hand with the acute hospital and on the other hand with hospital accommodation and domiciliary care services. Because no total programme has been formulated and because the Government has been preoccupied almost solely with acute hospitals, the community has more acute hospital beds than it really needs. But many of the occupants of those beds are there because they cannot afford nursing care in nursing homes. On the other hand, there are many occupants of nursing homes who are there not because they require nursing home care but because no adequate hostel accommodation or domiciliary care services are available for them. I am reliably informed that 30 per cent of nursing home patients in South Australia could be cared for in hostels, in day centres or by domiciliary care services. This would be cheaper for the patient and cheaper for the Government and, above all, it would provide the patient with better care in that the care given would be more appropriate to the patient's needs.

However, the most urgent need is for the cost burden to be taken off the shoulders of nursing home patients. This burden has been a crushing one. For many people it has meant using up their savings or having their nursing home fees paid out of the wages of sons and daughters who have their own families to support as well. This Bill reduces the amount that must be found by the patient or the patient's relatives to pay the nursing home fees and, for that reason, the Opposition will not oppose the passage of the Bill. However, it is quite inadequate in itself, because before very long nursing home fees must rise again and we will be back to the same situation as before.

What must happen is that the sick and the aged must no longer have to pay the cost of nursing home care. The cost should be no charge on the patient at all in the same way as acute hospital care already is no charge on insured patients. Having made nursing home care a charge on the public purse, the cost should be kept within reasonable bounds by upgrading the scope of hostel care and domiciliary care which will mean an improvement in the quality of health care and a lesser charge on Government revenue.

There must be also, 1 believe, much more direct Government activity in the field of nursing homes. I refer in this respect to the report of the Senate Select Committee on Medical and Hospital Costs which, at page 54, recommends:

That, as a means of overcoming shortages of nursing home bed availability, and to establish State Governments as being primarily responsible for providing nursing homes within the total hospital care concept, the Commonwealth Government should make unmatched grants to the Stales Ibr the construction, or enlargement, of State nursing homes.

I agree that the Commonwealth Government must either give more support to the State Governments or help local government authorities and that, if it does not do this, it should go into the field itself and construct its own Commonwealth nursing homes.

The second principal feature of this Bill is the doubling of charges on national health service prescriptions. The charge is increased from 50c to $1. This measure is completely unacceptable to the Opposition. We will oppose this measure in the Committee stage and we would have opposed the whole Bill if the Bill did not provide for nursing home benefits to be increased.

The policy of the Australian Labor Party is that pharmaceutical benefits shall be provided without charge to the patient. The concept of a deterrent charge is really illusory when we consider whom we are trying to deter. In the first place, the prescription is made out by the doctor who does not have a direct financial interest in the cost of the prescription. So, the effect that the deterrent charge will have will vary according to the degree to which the doctor is prepared to compromise his patient's medical welfare in order to safeguard the patient's financial welfare. We should not be putting doctors in this position.

However, if it is assumed, for argument's sake, that there is some deterrent effect on the patient, it is more likely to be the poor man than the rich man who will be deterred. The poor man may be deterred from obtaining some medication that he really needs. Meanwhile the rich man will not be deterred even if his medical need is less. In other words, the deterrent charge does not deter the less sick; it deters the less rich. Whether there is a deterrent effect or not,, a charge of Si on national health scheme prescriptions can amount to a considerable sum if a number of different medications are prescribed and if repeats are prescribed also. Taking this and the doctor's fees into account we see that quite a considerable sum is involved.

I could quite understand many people now regarding the Government's claim to providing a pharmaceutical benefits scheme as fraudulent, because although the cost per prescription has risen only marginally, the patient's contribution is now to be doubled in one stroke. According to the figures of the Minister for Health (Senator Sir Kenneth Anderson), 10 years ago the average price per item was $2.18. The patient's share was 50c; in other words, 23 per cent. Now the average cost is to rise from $2.18 to $2.30, and the patient's share will be $1. So the patient's share per prescription will be increased from 23 per cent to 43 per cent. Many- more prescriptions are now being written so the Government has decided to make the patient pay a greater share. The . Government is increasing the number of benefits available, and thereby hopes,- presumably, that it will gain political mileage, but it is not prepared to pick up the check. As it was put to me by a correspondent, it is like inviting someone to a fine dinner, then complaining about the cost and asking the guest to put his hand in his pocket to help pay the account.

Of course, it is proper for the Government to investigate the causes of the rising cost of the scheme, and this is currently under consideration by the House of Representatives Select Committee on Pharmaceutical Benefits, of which I am a member. I am not in a position to determine what the findings of the Committee will be, but I am prepared to say that raising prescription charges is a most iniquitous way to try to cut costs, besides not being conducive to good medical practise. The level of expenditure on pharmaceutical benefits is almost as great as the expenditure on medical and hospital benefits combined. It is continuing to rise steeply. There is a much greater amount of drug consumption in Australia. Therefore, I think it is time that we started asking: Are we getting any healthier as a result of this? Again, ] shall not, as a member of the Select Committee, presume to answer this question, but I shall say that it is not sufficient just to look around for scapegoats. We must look at the whole social and physical environment in which people are seeking and taking more medication.

The third principal measure in this Bill is to approve by legislation the increases in doctors' fees which were introduced earlier this year. I believe that we are now at the crossroads in medical insurance. Costs are spiralling. We are now legislating to raise fees. How many more times will we go through this process before we stop and ask where it is getting us? We are at the crossroads in health insurance as we are in the care of the chronically ill, about whom I was speaking earlier. Are we going to wait until nursing home fees rise again before we ask: Are we getting the best in nursing care for our money? So also for health insurance. Medical fees are rising rapidly. During the 12 months between December 1969 and December 1970, the period during which the revamped national health scheme was introduced, doctors' incomes rose by 25 per cent - not this doc tor's income. We are now accepting a rise of 15 per cent in general practitioners' fees. Commonwealth expenditure on medical benefits has more than doubled in the last 5 years. I might mention in passing that hospital charges are also rising at a phenomenal rate.

The document which was circulated to honourable members today by the Minister for Health indicates that public ward charges in South Australia are $16 a day. I do not think it is very long ago - a couple of years ago - when the charge was $10 a day. This is a pretty heavy rise. At the same time an increasing proportion of funds used for current expenditure on public hospitals is coming from State government sources. So State governments are having to pay increased amounts. In summary, there is a rapidly increasing expenditure on hospital benefits, medical benefits and pharmaceutical benefits. The percentage of our gross national product which we are spending on health services is also rising. I have some figures here which I obtained from the Bureau of Census and Statistics today, which show that excluding chemists' charges, 3.3 per cent of our gross national product was spent on health in 1959-60, 3.7 per cent in 1964-65 and 4.1 per cent in 1969-70. If one includes chemists' charges, 4.9 per cent of the gross national product was spent on health in 1959-60, 5.4 per cent in 1964-65 and 5.8 per cent in 1969-70. So we must really ask the same question as we asked in relation to pharmaceutical benefits: We are spending more on health, but are we getting any healthier? It is quite possible that expenditure on health will continue to increase without it really doing anybody much good.

It is quite clear that a first reform must be to abolish the present system of voluntary health insurance, and this is the first thing that a Federal Labor government will do in this field. We will abolish the system of voluntary health insurance. We will introduce universal health insurance with contributions based on ability to pay. The setting up of a single Government scheme will save funds by reducing the cost of collection of revenue, which can be done through the Taxation Office, and by avoiding the other problems associated' with having a multiplicity of funds, such as advertising costs and the need for each fund to carry a surplus. Payment through this fund will be by fee for service.

However, Labor will also establish a system of staffing public hospitals with salaried medical officers. A system of comprehensive community health services .will be set up with the family doctor as one of the team, with nurses, physiotherapists, medical specialists, social workers, dieticians and so on. In this context I believe that we can, we must and we will evolve in the direction of a fully salaried medical service. The tendency has already become evident for increasing numbers of graduate doctors to enter ii. to salaried positions, and I believe that this tendency will continue. Thus I believe that a salaried medical service involving the great majority of doctors will come, not at the behest of an authoritarian government, but by evolution because it is consistent with the best in medical care.

Not only will it be best for the patients; it will be far less extravagant than the present fee for service system. Indications from the pre-paid systems, such as the Kaiser Permanente Scheme in the United States of America, suggest that the number of acute hospital beds required can reach as low as 2 per 1,000, or even less. Another benefit is the decrease . in the number of operations the merit of which is sometimes disputed. I refer to tonsillectomy and hysterectomy operations. Furthermore, I believe that the potential exists for reductions in expenditure on prescription goods in a pre-paid medical system. One of the best examples of the merits of a salaried service can be seen by reference to my own specialty of anaesthesia. The specialist anaesthetist is highly trained in a number, of specialised tasks, such as the administration of anaesthetics, supervision of patients in the post-operative recovery ward, intensive care of patients with life threatening respiratory and circulatory conditions, the management of unconscious patients, and the relief of pain such as that associated with the early post-operative period, with certain chronic diseases or with child birth.

In the public hospital the specialist anaesthetist can devote his whole time to these activities. He himself can- handle the more difficult anaesthetic problems and can leave the simple cases to non-specialist staff. Thus he uses his specialist skills all the time - a productive use of manpower. Contrast this with the specialist anaesthetist in private practice. He gives only anaesthetics, and many of these could be handled by a competent general practitioner. The rest of the time is spent shuttling through city traffic from hospital to hospital. How utterly wasteful. Meanwhile, the post-operative care and so on in the private hospitals is carried out by the nursing staff. This is a responsibility which nurses do not have to bear in public hospitals. This is particularly topical in relation to the present measure because one of the items in the Schedule for amendment is item 44. The pre-operative or preanaesthetic visit by an anaesthetist involves a further waste of time, which is quite unnecessary, and would not take place in a fully salaried hospital system. So I say to the Government: Put the fees up now, put nursing home payments up now, put prescription charges up now, but sooner or later a decision will have to be made as to whether any better service is obtained for the extra money.

I think that there are plenty of examples to indicate that the present system positively encourages a waste of money and manpower. To take an example, a multiple electrolysis determination attracts a fee of approximately $15. I have a strong suspicion that this service is greatly overpriced. There is a great tendency to have this examination carried out on many patients, but there is scant evidence to indicate that screening the community in this way will result in a healthier community. Yet the over-priced benefit gives the opportunity for pathology specialists to make handsome incomes, although I do not claim that they necessarily do this. But certainly the system can encourage scarce medical manpower into this specialty without great return in the form of community help. Not nearly enough is being done to determine the medical manpower needs of the community. I believe that this should be the primary task of the medical faculties in our universities. Certainly some of our medical teachers are giving a splendid lead, and I have particularly in mind Professor Saint in Brisbane and Professor Hetzel of the Monash University. A Labor government will give every encouragement to medical skills to become fully involved in community medicine. I would like to quote from a recent article by Professor Saint in the 'Medical Journal of Australia' in which he suggested that medical schools must involve themselves more in community medicine. It reads:

And in few hospitals is much Interest paid to the long-term supportive care.

This was referred to by my friend the honourable member for Isaacs (Mr Hamer). It goes on:

Pejorative adjectives are used to describe old ladies with strokes and old gentlemen with bronchitis; rehabilitation is something somebody else does; and what skills the social worker, the physiotherapist and the occupational therapist employ are known only to undergraduates who marry them.

He went on to say: . . if we believe it to be true that the range of experience of the doctor-in-training should be broadened, then we should be creating elective attachments and a teaching atmosphere in a spectrum of institutions which have not hitherto been regarded as being worthy of affiliation with medical schools - industrial health clinics, geriatric day-centres, rehabilitation centres, psychiatric clinics and day-centres, clinics for drug addicts, child guidance centres, and remedial centres for autistic and dyslexic children. And the answer to the problem of rejuvenating interest in general practice and the elevation of its prestige is not only to attach students to individual practices, desirable though this may be, but to create pioneering academic units in community health ...

He went on to say:

.   . and to experiment with the design and organisation of health centres, something which we have scarcely begun to do in Australia.

In the final analysis what really matters is deciding where best to spend our money to achieve a high standard of community health. This means not so much more and more on doctors' fees, on hospitals or other institutions. It means preventive medicine. It means reducing the incidence and prevalence of disease. And preventive medicine is meant in the widest context. It may mean anti-pollution measures to reduce respiratory disease; it may mean measures to improve the urban environment to reduce the incidence of psychoneurosis; it may mean safer motor cars and better road rules to reduce injury from road accidents. Again, as Professor Saint said, there is so much more which ought to be done which is not being done at all.

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