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Thursday, 6 December 1973
Page: 4404

Dr CASS (MARIBYRNONG, VICTORIA) (Minister for the Environment and Conservation) - I believe that recently the honourable member for Hotham indicated that the Government scheme would really only assist the no-hopers. I do not know what sort of definition he applies to them. But leaving aside the no-hopers, he mentioned also that pensioners would be better covered by our scheme and he in turn is proposing the same sort of thing. Of course, the Opposition had 23 years in government to provide for these deficiencies which it is now suddenly prepared to concede do exist. No one stopped the previous Government from doing something about them.

Another point the honourable gentleman made was that he wished to see appropriate deterrents for unnecessary use of hospital and medical services by patients. I want honourable members to think carefully about that. The suggestion is that if health services are available free, for some reason or other people will go along and use them whether they need them or not - simply because they are free. I suppose the line is: 'Yesterday I could not afford to have my appendix out because it was going to cost me so much, but now that I can have it done for nothing I may as well go and have it done.' Surely one seeks medical treatment because one feels one needs medical treatment. One does not seek medical treatment solely because one can afford it. I would not even claim that today for the rich who arc better able to afford medical treatment and perhaps get treatment more often than others do. But I do not believe for one moment that the rich get treatment simply because they think they can afford it and therefore they will have it. They obtain treatment because they feel that they need it and fortunately for them they can pay for it. But in many situations these days less well-off members of the community have to think twice; whilst they may feel that they need treatment they have to weigh that against the cost to themselves, and they take the view that with a bit of time perhaps they will get over the problem, anyway.

Then mention was made of the fact that a tribunal would be necessary to ascertain what the level of medical fees should be and, of course, it was not unreasonable to hope that a reasonable number of doctors would adhere to these fees. We were not the ones who discovered that this is a problem; the last Government experienced this self-same problem of finding the medical fees going up in leaps and bounds. It even appointed tribunals and instituted inquiries to seek to find some way to control the ever increasing medical fees. When the common fee was finally agreed upon, rather grudgingly and after difficult negotiations, we then had the galling experience of finding increasing numbers of doctors very quickly departing from the schedule of fees. Even the Liberal Party Government was mumbling about the steps which might have to be taken in order to ensure that doctors would adhere to the schedule of fees.

Then I come to the amendment which, in essence, contains the criticisms of our proposal. The quality of medical care, we are told, will be lowered by our proposal and, as an indication, the first point discussed was hospitals. Of course, we have to concede that at present the average person is, in the main, unable very easily to get into a large public hospital for a variety of reasons, not the least being that he is often means tested out of those hospitals, and that is part of the problem. So in other words, where there are large public hospitals with a capacity to provide specialist medical care, the indication for admission is either that a person is a pensioner, or he is means tested in because he does not have the prescribed income or he is a special case for which no other facilities are available anywhere else. But any other medical indication which ought to reasonable and proper does not count if a person's income is so high that he cannot be admitted, because he is means tested out of that hospital.

In other words, in my opinion, under the present system there is a wastage of specialist facilities in the large public hospitals because admission is not determined solely on medical indication, and in my view that is the only reason why people should be admitted to our large intensive care hospitals. It should not be based on a person's capacity to pay or on whether he is so poor that he cannot be sent anywhere else even if the need is a relatively minor one. The indication for providing such expensive sepcialist facilities in large public hospitals is because they are needed for medical reasons, but because that is not what is fulfilled under the present scheme.

We anticipate that when anybody, irrespective of his means, is allowed to be admitted for standard care treatment in a large public hospital, the justification for admission will become medical indication only and nothing else, and that will ensure that the facilities are used to the best advantage for the community. We will not have, as is often the case now, these very expensive facilities - they are expensive because they must be provided for the most complicated medical care, but they are not used for that purpose all the time - being used in fact for patients who could well be treated elsewhere in much lower cost institutions.

We are then told that with the institution of our scheme there will be a sudden demand for 900 extra standard ward beds in the Melbourne area, as if suddenly so many more people will need to be admitted to hospital. That is a dishonest argument. What it really amounts to is that because of the availability of standard ward care, more people will be able to be admitted to such beds - they are excluded now because of the means test - and/ or alternatively they will want to be admitted to standard ward beds, but that will not be because they generate new illnesses; it will be the same illnesses which now would force these people into private beds. So, if 900 more standard ward beds are needed, 900 fewer beds will be needed in private or intermediate wards. Honourable members opposite cannot tell me that simply by passing the legislation, suddenly so many more people will become ill and need admission to hospital. I pointed out earlier that the criteria for admission under our system will not be that a person feels like it but simply - and this is the way it ought to be - because medically he needs it.

We hear a lot about the increase in cost, and we were assured that the Liberal Party's proposal to cope with the few minor deficiencies, such as providing for pensioners and those not covered by the present scheme would require relatively minor adjustments to the present best scheme in the world. But of course the reality is that this has been costed by the Department of Social Security. On the basis of the present scheme and the way payments are made, the cost to provide these minor adjustments would be the not insignificant sum of $200m to $300m. We are hoping that by readjusting the present scheme and by doing away with the gross wastage of the multitudinous health funds competing with one another, with all their administrative costs, we will encompass these minor adjustments foi much the same expense with which we are faced at the moment, or with a relatively minor increase.

Whenever the cost of the present health scheme is discussed it always strikes me as incongruous how no one takes into account or seems to notice the savings that would result from abolishing or doing away with the need for all these multitudious benefit funds - we are not going to abolish them because if people still wish to use them they are free to do so - which now spend at least 25c of every dollar they collect purely in administration.

It does not mean that our scheme will require increased public service administration because the technique of collection can be wedded into our present collection schemes - the taxation system and the Department of Social Security which already handles much more money in the way of payments to pensioners and so on every week than health funds do, anyway.

The next point made related to the apparent loss of the freedom of choice, and we were assured that under our scheme patients will not have freedom of choice of their doctor if they are admitted to the standard ward of a hospital, such as the Mercy Hospital. Let us try to understand what happens today in such private hospitals. A person does not bowl up to the door of the Mercy Hospital and say: I want to be admitted and I want Dr Bloggs to treat me'. He first has to go to Dr Bloggs. If Dr Bloggs happens to be in the custom of referring patients to the Mercy Hospital and he is accepted as one of the doctors who treats patients there, that person is admitted. But if Dr Bloggs never treats a patient at that hospital or never admits a patient to it, the chances are almost certainly that if he rings up and says: 'Mrs Jones wants to be admitted. I have never admitted a patient to yow hospital but she wants to go there', he will be told: 'Well, sorry doctor, we do not have any beds because we have our regular staff. Under our proposal the same thing will hold. We are simply suggesting that standard ward beds ought to be available in the Mercy Hospital but that to be admitted to that hospital ;t person will have to be referred by a doctor who traditionally works at that hospital. It is the same in a large public hospital.

Mr Ian Robinson (COWPER, NEW SOUTH WALES) - Oh I

Br CASS - The honourable member can say 'Oh' but the reality once again is that when a person goes to the casualty department of a large public hospital today - where I concede there is no freedom of choice - he is treated by the doctor on duty. This happens under the previous Government's scheme. It will not change for that type of admission. If you go to the hospital because you are referred to a large public hospital by your own general practitioner, he does not treat you in the large hospital but refers you to a specialist of his choice who he knows is on the staff of that hospital. It will not change with us; it will be exactly the same. You have the same limitations on freedom under the present scheme as you will have under our proposal. It will be no different. In other words, there is no such thing as complete freedom of choice anywhere in Australia now. For admission to large hospitals whether private or public, you have to get into either of them by being recommended through a member of the regular medical staff attending either the private of public hospital. To say that we will introduce some limitation is sheer humbug. To put it in another way, the Opposition does not understand how the present scheme works.

Next, we had the claim that specialists now treat patients in public hospitals in an honorary capacity - a very generous donation to the community. They treat private patients and charge fees. Estimates have been made that some leading consultants working in large public hospitals spend a large proportion of their time attending to their duties in the large public hospitals. They may attend the hospital two or three sessions a week at least; they are on call; they have either to attend outpatient clinics or perform operations and conduct ward rounds in the hospital. When you add to that the time they have to spend travelling - often they work in private capacities far from the large hospital and in private institutions all around the city - you may well find that perhaps at least 30 per cent of their time is spent in treating patients in an honorary capacity. Perhaps they spend as much time again in travelling around the countryside getting from home to the consulting room and to the hospitals. You may well find that they are expected to earn their living in less than half their working week, perhaps 40 per cent. So, of course, they have to charge exorbitant fees.

One could well ask why the rich, those who can afford to pay fees, should be bled so severely financially to enable treatment for the poor to be provided by the specialists in an honorary capacity in the hospitals The reality is that the medical profession has become sick of this. The Australian Medical Association no longer approves honorary services by consultants in large public hospitals. The Association is in favour of either salaried medical service or sessional payments for consultants working in the large public hospitals. We are not proposing anything revolutionary. If my recollection serves me correctly, the Association has been opposed to honorary medical services in large public hospitals for many years.

Then we had the claim that there would be an increase in the cost of the scheme due to over-utilisation. I have touched on this matter before, namely, the horrendous suggestion that if you can have an operation for nothing you will have it, whereas if you have to pay you will not have it. That is true, if there is a medical indication for it, I suppose. Indeed I am sure that is so. In some situations you may need an operation for a hernia but, because it will cost too much money, you will put up with the hernia. But to suggest that you will have an operation simply because it is free is ridiculous. Surely there is always a medical indication for people who seek surgical treatment.

A couple of years ago figures were examined by a Dr Jim Lawson, who was seeking to ascertain some guidelines for forecasting what hospital bed needs might be for surgical treatment in the community. To find out, he analysed the incidence of operations in Australia, the United States of America and Great Britain, and he uncovered some very interesting facts. In Australia, where doctors are paid on a fee for service basis, he found on a sample of over 8 million services - he used all the health fund statistics - that the tonsillectomy and adenoidectomy rate, in this country, mainly for children, was seven per thousand. He found that in the United States of America where they have fairly extensive salaried medical schemes - ironically in God's own country of free enterprise - they have doctors working on salaries - the operation rate for the same diseases was only four per thousand. He found also in the statistics from the United Kingdom, where doctors are on salary, the operation rate was 3.6 per thousand.

Are we suggesting that Australian children are twice as ill as American or English children? I should think that many people would claim that our children are healthier than in either of the 2 countries, because we have fewer people who are less well-off and living in less adequate conditions. Under fee for service it seems that, despite the claims that doctors on salaries will promote overutilisation, the reality is that you have twice the utilisation with a fee for service system as you have with doctors on salaries. In regard to appendicectomy, the rate was five per thousand in Australia, 1.4 per thousand in America with salaried doctors and in the United Kingdom 2.5 per thousand with salaried doctors. There was an interesting control and it might be said that this was because doctors on salary were lazy and would not do the job. In the case of herniorrhaphy the patient can know that he might need an operation, whereas he depends on the doctor's judgment in relation to his tonsils or appendix. For herniorrhaphy the rate in Australia, where the patient has to pay a fee for service, is 1.5 per thousand. In the United States of America it is 1.9 per thousand and in the United Kingdom it is two per thousand - not much of a difference, but an increase. In those countries the doctors are on salary. This suggests that where the patient does not have to pay but knows he needs the operation and can afford to have it done because the doctor is on salary, he has it done. Let us not believe the nonsense that a salaried service means an increase in utilisation.

Even the President's task force in the United States of America found that where salaried medical service holds, the utilisation rate for hospital beds was often 30 per cent less than when doctors were paid on a fee for service basis.

Finally, in case one suspects that the quality may be inferior, they also found on examination of equivalent populations that the perinatal mortality rate was lower in places where the doctors were salaried.

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