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Wednesday, 13 October 1971
Page: 2280

Dr CASS (Maribyrnong) - 1 wish to talk to that part of the Opposition's amendment that relates to nursing homes. If one examines the number of nursing home beds per thousand of population one sees that there has been a dramatic increase from about 1.48 beds per thousand in 1963 to 2.42 beds per thousand in 1970 in the private nursing home sector in a period when the number of public nursing home beds rose from only 0-86 per thousand to 1 per thousand. In other words, there has been a very dramatic increase in the private sector. The fees for these private beds amounted to a total of about S3 8m in 1966-67. The Commonwealth paid $15m of that sum. So the Commonwealth Government is providing quite a large subsidy to the private nursing home business.

The honourable member for McMillan (Mr Buchanan) indicated that about 80 per cent or more of the beds in these nursing homes are occupied by pensioners. Of course, the funds to pay for the occupation of these beds come from the Commonwealth allowance in the main and the pension the Commonwealth pays to pensioners. So that one could in fact say that the Commonwealth provides all of the funds of these institutions - in other words, the pension and the Commonwealth payment. With the increase that the Government is now proposing, theoretically if the costs remained the same as they were for the financial year 1969-70 the pensioners would make a very slight profit. They would finish up with about $7 a week in their pocket. But since those days costs have already risen. We have heard a lot about this in discussions on inflation.

Accepting the figures of the honourable member for McMillan, we see that already the combined pension and the Commonwealth payment - in other words, total taxation revenue - will not be sufficient now to pay the fees. So, in addition, the pensioners' families are going to have to find still more funds. Of course for the non-pensioners this will represent an enormous financial drain. I would hazard a confident guess that the cost of public nursing home beds is considerably less than this, but we cannot prove it because the figures for public nursing home beds are included in the total public hospital bed costs. We cannot tell what the figure really would be. But I think that one can get a fair indication of it from the very dramatic increase in the number of private nursing home beds.

We can get a pretty shrewd estimate of how profitable these types of institutions are to private investors. No-one is forced to go into the private nursing home business. Quite clearly, if people invest their money to change small houses and goodness knows what into small, to me inefficient, private nursing homes they must be doing it because they can make money from it. I am quite confident that this is in fact what is happening. In essence all we are doing is subsidising these very inadequate facilities for the treatment mainly of pensioners. In all these discussions we fail to ask what it is we are really trying to achieve. We fail to ask whether private nursing homes are worth while and what function they fulfil. Again accepting the figures provided by the honourable member for McMillan, I would suggest that the main function of private nursing homes is to keep old people out of sight and so out of mind. But this is not good medical care. The essence of medical care for people in that age bracket these days is active, intensive medical care and active rehabilitation services. None of these things is available in small private nursing homes.

It would be far better to extend domiciliary care in association with geriatric medical teams based on large public hospitals, lt would be far more humane, much more effective and, incidentally, would cost the community much less than the present system of maintaining these people in private nursing homes. In my opinion, old people confined to nursing homes are often condemned to a living death. The Australian Labor Party's concept with the ultimate aim of a completely comprehensive medical service for ail age groups is far better. Convalescent and nursing home type beds should be incorporated in the active aspect of medical treatment. These beds should not be in tin pot little institutions that must be inefficient. They should be incorporated into satellite hospitals in a regionalised hospital system. With these smaller institutions the convalescent beds or the nursing home beds should be in smaller hospitals than the major centres but .still in groups of perhaps 50 to 100 or more beds - not smaller than that. They should be situated near where the patient lives - in other words, out in the community - and near where the patient's general practitioner works. They should operate in conjunction with health centres, comprehensive units where one can go along and see one's general practitioner and get the assistance of social workers, occupational therapy and X-ray facilities. I will enlarge on that later if there is time.

I turn now to the question of prescription charges. The honourable member for

McMillan revealed a snide suggestion based on having heard that the pharmaceutical industry is going to raise the cost of a lot of the cheaper items so that they will be above $1 and will be covered by the new scheme. If they are below SI, one just pays the fee. The industry, he said, is going to bump the fees up so that the patients will have to pay $1, the Government will pay a few cents and when the next lot of statistics comes out there will be shown a dramatic drop in the cost to the Commonwealth of prescriptions. There will be a very serious increase in the cost to the community which will not be measured. We will not notice it. The reason for making this charge is often claimed to be that it will help to deter people from wanting unnecessary prescriptions. The fact is that doctors prescribe medicines for patients. Patients do not prescribe them for themselves. Patients do not get the medicines unless they have prescriptions from their doctors.

The fault lies not with the patients but superficially with the doctors. I would like to suggest that it is not even the doctors' fault. It is the fault of the system under which the doctors have to practise medicine. At the moment there is an economic incentive for doctors to write, prescriptions much more readily than they should. It is an easy way of coping immediately with the problem of the patient who has an indefinite illness which may require a lot of discussion for a much longer period than is economically worth while for the doctor. After all, if he sees a patient with a psychosomatic illness and talks to the patient for half an hour or three-quarters of an hour he gets the same fee as he would get if he spent 5 minutes with the same patient and prescribed a tranquilliser. lt costs the community much more. He earns less if he spends the extra time. But of course if he spends the extra time the patient will be better off and will receive better medical treatment. So the pressure to increase prescribing is due to the fact that the doctor is paid on a fee for service basis. Therefore he has an economic interest in churning the patients through.

An article which appeared in 'Fortune' magazine of January 1970 may help to illuminate the matter. It discusses some of the various schemes in America which have varied the concept of fee for service medical care. One is the Kaiser plan whereby physicians in all major specialties are housed in large clinics in each of the regions covered by the plan. When a patient comes along he can see the doctor and then he can go to the X-ray unit in the same building and have special investigations done. If he needs hospitalisation he can go into one of the hospital units which usually adjoin these clinics. In other words, they have adopted the very policy that the Labor Party is proposing of an integrated health scheme with satellite hospital beds associated with health centres. Let me come to the question of the rate at which patients receive medical care or the effect that fee for service has on the treatment that is offered. Under the Kaiser scheme, the doctors are paid salaries. Noone is forced to join the scheme. No doctor is pressganged into becoming a socialised doctor. They voluntarily become salaried medical officers.

The patients are free to choose any doctor within the group they go along to see, as they may in our country. If you go along to a group of private doctors you are free to take your pick. The article says:

Even though there is no limit to the number of times a member can see a doctor, members of the Kaiser plan make slightly fewer visits to doctors than the public in general.

Comparing the Kaiser members With the population of California at large, the Kaiser member spends 69 per cent as much time in hospital as other people seeing doctors who are paid a fee for service. The Kaiser health service costs from onequarter to one-third less than the same package of services would cost outside the system. I insist that I am not talking about Communist Russia. I am talking about capitalist America and, as my colleague the honourable member for Kingston (Dr Gun) indicated, the evolution of salaried medical services which are beginning to provide the sorts of services we have been talking about for a long time. Under such a scheme there are considerable savings on hospital and medical costs. There are even reductions in the frequency of- operations. For instance, it has been suggested that if your doctor is on a salary you are far less likely to suffer from appendicitis. Those people who are treated by doctors paid on a fee for service basis appear to have appendicectomies 86 per cent more frequently than comparable people treated by doctors who are paid a salary. Also, 50 per cent more women need to have hysterectomies when they are treated by doctors paid on a fee for service basis than when they are treated by doctors paid a salary. The differences are quite dramatic. 1 will conclude, since I see that the Leader of the House (Mr Swartz) looking at the clock, by saying that the same situation applies in Australia. I repeat that these were the conclusions reached in the United States of America, which is not a country forcing Socialism on anybody. Therefore, the only hope is to get more value for the money spent on medical care, to remove the glaring inefficiencies, to bring the proper incentives into play and to make the maximum effort to supplement doctors with the lower paid paraprofessionals. If this were done the country might save enough from the elimination of waste to do a creditable job with the same 6.8 per cent of gross national product which it now spends on its health services. The strongest evidence that this is possible comes from abroad. Honourable members should note this because this deals with quality which is something the Minister suggested should be considered. Sweden and Britain which enjoy lower infant mortality and morbidity rates from childhood diseases than the United States devote only 5 per cent and 4 per cent respectively of their gross national products to medical care and in each of these countries doctors in most cases are paid salaries rather than fees for services.

So when we suggest that the tendency which is automatically occurring in this country is for more and more doctors as they graduate to seek employment on a salary basis we are not talking about the need to nationalise anything. We are observing a natural development. We think it will be inevitable. The Government ought to recognise the trend and assist the development of these institutions by not continuing to subsidise inefficient private nursing homes but by encouraging the development of the public nursing home sector, the integration of the whole hospital organisation, and by increasing the salaried medical services in those institutions.

Question put:

That the words proposed to be omitted (Mr

Hayden's amendment) stand part of the question.

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