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Wednesday, 3 October 1984
Page: 1506


Mr CARLTON(5.27) —We are discussing the Health Legislation Amendment Bill 1984 and the Social Security and Repatriation Legislation Amendment Bill ( No. 2) 1984, which were introduced by the Minister for Health (Dr Blewett) when the House was last sitting. The two Bills are omnibus measures. Some of the measures flow from the Budget. The Opposition has no quarrel with the Social Security and Repatriation Legislation Amendment Bill. We support that Bill and the measures contained in it. The Health Legislation Amendment Bill has nothing in it that we wish to oppose, but it touches on two areas-nursing home benefits and the 35-day rule for hospital patients-in a way that leaves the main problems in these areas virtually untouched. Therefore, as an amendment to the motion for the second reading of that Bill I move:

That all words after 'That' be omitted with a view to substituting the following words:

'whilst not declining to give the Bill a second reading, the House is of the opinion that the Bill does not deal adequately with the serious problems faced by the long term sick and elderly caused by the Medicare 35 day rule, and calls on the Government to withdraw the 35 day rule until proper arrangements have been made to care for patients affected by the rule.

Before I go on to the main issues, I ask the Minister to clarify his intentions in regard to clause 9 of the health Bill, which inserts a new section 3C. The Bill uses the term 'health service' rather than 'medical service' in giving the Minister power to determine that a service is eligible for medical benefits where the service is not listed in the medical benefits schedule. Is it the Minister's intention to use the power to include health services not previously eligible, for example chiropractic services? I would welcome clarification on that point during his reply.

I turn now to our main concerns with the Health Legislation Amendment Bill. Clause 12 makes allowance for the payment of nursing home benefits where a patient is temporarily absent and for the bed to be available for respite care. In other words, if somebody is away for a few days it is possible to use that bed to relieve the pressure on a family caring for somebody who is infirm. That person can occupy the bed in the interim. He goes back when the original patient returns. This measure is good as far as it goes but it highlights a general nursing home problem which has been getting very much worse since this Government took office in March 1983. The Government says that it favours a move towards domiciliary care and, as part of that program, it froze nursing home bed approvals for 15 months. After that it introduced new guidelines for the approval of nursing home beds but those guidelines are so restrictive and depend so much on the proposed move towards domiciliary care that they amount to a virtual freeze continuing on nursing home bed approvals.

As part of this admirable intention to try to assist people to stay at home and be in the right kind of care, proposals have been advanced to improve assessments of the sick and elderly so that they can be put into the right kind of accommodation or assisted to remain at home. Eighteen months down the line those assessment arrangements are very much still in embryo. Therefore, they are not really available to the whole of the country. Certain teams are testing these things out in parts of the country but there is not in place a proper geriatric assessment system.

In the Budget the Government indicated that it would bring in a new home and community care program as part of its intention to favour home care. The program was for $300m to be spent over three years. One noted that at the end of 18 months of talking about this the Government gave only $10m of new money in the 1984-85 Budget year for the home and community care program. Fundamentally, this Government and this Minister have imposed a fearful freeze on nursing home accommodation without having introduced the necessary additional measures to make it easier for people to go into other types of accommodation or to remain at home. The cart is definitely before the horse.


Mr White —They have nowhere to go.


Mr CARLTON —As my friend the honourable member for McPherson rightly says, they have nowhere to go. The really cruel aspect of this is that there is additional pressure on nursing home accommodation caused by the 35-day rule and the procedures for section 3B certificates which are referred to in this Bill.

The Bill makes a trifling amendment to the section 3B arrangements. We agree with the change. It is to make section 3B certificates available 14 days before the 35-day period is up, as opposed to the previous seven days. That is okay but it is a minor change. I will put this into perspective by explaining to the House exactly what a section 3B certificate is and what the 35-day rule is. Section 3B is a section of the Health Insurance Act. It relates to the certificate that a doctor has to sign for a patient to continue receiving full acute care benefits in a private or public hospital. If a person with an acute illness has been in hospital for 35 days a doctor must sign a section 3B certificate to certify that that person requires continuing acute care; otherwise many dreadful things happen to that person.

Under the arrangements that were in place before Medicare came in on 1 February 1984 and the arrangements operating under the previous Government, a section 3B certificate could be issued if a patient was in need of one of four things. He could have been in need of acute care, professional attention for an acute phase of his condition, active rehabilitation or continued management for medical reasons as an in-patient. A doctor had four reasons for signing a section 3B certificate. In addition, the certificate did not have to be signed until the sixtieth day. On 1 February 1984, the Medicare day, the only ground on which a section 3B certificate could be issued was that the patient was in need of acute care. That wipes out the other three-professional attention for an acute phase of a patient's condition, active rehabilitation or continued management for medical reasons as an in-patient.

How does this affect patients? First of all, it has a very severe effect on psychiatric patients. They may require professional care for an acute phase of their condition, such as a chronic schizophrenic requiring hospitalisation when the chronic illness temporarily worsens, leading to the need for professional attention in a psychiatric hospital. Psychiatric patients needing rehabilitation , such as those who are no longer acutely ill but who require retraining or resocialisation before they are capable of re-entering the community, are also excluded from coverage under the new section 3B certificates. By the deletion of continued management from the criteria a psychiatric patient unable to cope in the community cannot turn to psychiatric hospitals to manage behavioural or other problems. It may be extremely difficult for him to manage outside a hospital; yet he is precluded from hospital treatment because he does not necessarily qualify as being in need of acute care.

The abovementioned limitations upon the certification of patients under the new section 3B legislation effectively discount psychiatric disorders from being genuine illnesses for the purposes of defining long-stay patients. The same picture is evident for medical patients-patients not in need of surgery yet in need of professional attention for an acute phase of a more chronic illness, active physical rehabilitation or continued management for any medical reason. They are excluded from being bona fide hospital patients and are classified as nursing home patients irrespective of their condition. This clearly indicates that the Minister for Health sees psychiatric and medical hospitals and their long-stay patients in an entirely different setting to surgical facilities and their patients. That is a distinction which not only is difficult to understand but also is clearly discriminatory and totally unfair to medical or psychiatric hospitals.

Another major area of concern is the treatment of the dying. A patient may not be classified as needing continuing acute care but he may be extremely sick or in a terminal condition. Section 3B certificates cannot be signed for such people if they have passed through what is termed the acute phase. I am not making this up. I am getting many letters, as is the Minister. He knows this is happening. He has correspondence on it.

A neighbour of mine was in this predicament. Her husband was in a private hospital locally. He was told by the hospital that the 35 days was nearly up and that he was no longer classified by the hospital as requiring acute care. His wife was absolutely desperate as to where her husband should go because he was gravely ill. However, he did not meet the requirements for a section 3B certificate. My office rang every nursing home in the vicinity and beyond without any success because there are enormous queues for nursing homes. They are not in a position to take terminally ill patients in those conditions, given their present demands. I managed eventually to persuade a war veterans' home to take this person. He died three weeks later. All I can say is that when we see the distress of a person who has a relative in that condition, with all the normal distress of a situation where the patient is dying but who by these procedures is put to that difficulty, I think it is absolutely intolerable. I will make it more clear as I go on why I think this is one of the most outrageous measures I have seen in my life.

There are major difficulties for all hospitals in the wording of the section 3B certificates. Certification cannot be made retrospectively and certificates must be postdated from nought to seven days-in this Bill it will be 14 days-before they come into effect. Problems arise when the doctor or hospital is unsure whether a patient genuinely needs a section 3B certificate or continued hospital treatment. It is often difficult to substantiate objectively a claim that a patient is in need of acute care.

If the patient's doctor is unavailable during this period-he may be away on holiday-the hospital is be placed in the difficult position of not having the attending doctor available to complete a section 3B certificate. The other problem, of course, is that after 1 February, when Medicare came in, the penalties were increased on doctors signing certificates incorrectly. Making a false statement makes a doctor liable for a fine of $10,000 or five years--


Mr Donald Cameron —Ten thousand dollars!


Mr CARLTON —Ten thousand dollars. The honourable member for Moreton would know also that five years in prison is the other penalty for a doctor if the certificate is falsely signed. Doctors are certainly being intimidated by this qualification. They feel they are taking too great a risk to complete section 3B certificates for any patient if there is any doubt at all in regard to the acute nature of the patient's condition.

The other aspect of this legislation is that a section 3B certificate must not be made out retrospectively. In other words, if a person misses day 35 then that person has no redress. The form has to be filled in before the 35 days are up. People are now being given 14 days before that has to be done. There is a reason for that which I shall mention shortly. The next problem is that the health funds are given 60 days in which to object to a section 3B certificate. If an objection is raised, either by a health fund or by a delegate of the permanent head of the Department of Health, the certificate goes to an acute care advisory committee, which consists of a representative of the Commonwealth Department of Health as chairman, a representative from the State authorities, a representative from the Australian Medical Association and a representative from the health funds. The balance of power there is not exactly in favour of the doctor or the patient. All members of these acute care advisory committees must be medical practitioners.

The reason given by the Minister for extending the period for signing before the 35 days is up is to allow disputed certificates to go to an acute care advisory committee. But that does not meet the problem at all because the funds have up to 60 days to lodge an objection. So we can get a situation-incidentally , I will give a case shortly on this-where a certificate is disputed after 60 days, then it might be another two weeks before the acute care advisory committee can deal with the matter and then that acute care advisory committee can turn it down. Alternatively, it can make a recommendation to the permanent head or his delegate to accept but then the permanent head or his delegate can turn it down. That is a real difficulty. Honourable members can imagine the difficulties both for patients and for hospitals when there is this kind of delay.

Another problem with the questioning of section 3B certificates by this process is that it undermines the authority of medical practitioners. It means that claims officers working for a health fund may decide that a section 3B certificate is invalid for any reason and refer the matter to one of these committees without even giving the medical practitioner or the hospital involved the courtesy of explaining the individual patient's condition in more detail. The implication there is that not only are medical practitioners fraudulent but also they are careless in their issuing of section 3B certificates. It also suggests that claims officers or officers of the Department might know more about the condition of the patient than the attending medical practitioner. A further problem is that no guidelines have been issued by the Department of Health as to the definition of acute care. We find only the words 'requiring acute care'. It is now eight months since 1 February when this measure came in and we still do not have a definition of acute care for the doctors to follow. So the doctors are required to put on the line the possibility of being fined $5 ,000 or going to gaol for six months when the Department, after eight months, still has not given them guidelines to describe what 'acute care' means.

What happens when a patient does not qualify for a section 3B certificate? At that point the patient is classified as a nursing home patient. If the patient is in a public hospital that patient is required to pay 87.5 per cent of the age pension plus the supplementary allowance. So it is actually $12.40 a day. If an age pensioner claims free hospital treatment in a public hospital under Medicare and, at the end of 35 days, cannot get a section 3B certificate, having been classified for acute care, and cannot find accommodation in a nursing home and is too sick to go home, that person is then charged $12.40 a day-$86.80 per week -for free medical care under Medicare. How many people know that?

The more we look at this wretched scheme that this Minister has brought in the more we find that it is absolutely fraudulent. How many pensioners in Australia know that if they go to a public hospital they can be there after 35 days with nowhere to go, too sick to go home, and charged $12.40 a day for their bed? After 35 days they may well still have commitments at home. It is not as if they are suddenly transformed into a permanent nursing home type patient where it is proper to take 87.5 per cent of their pension as part payment for a nursing home bed. In this case they may only be there for, say, another month or two, but over that month or two they will be having to pay $86.80 a week in addition to all their other commitments under the free Medicare scheme. I think that is disgraceful. If they are in a private hospital they pay the $12.40 plus the drop in the fund benefit. If one does not get a section 3B certificate the fund benefit drops to about $68 a day from whatever it was before, depending on the category of hospital. So these people usually will be paying at least $50 a day in addition, depending on the category of hospital, if they are in a private hospital.

A lot of pensioners have taken out private insurance so that they can get into a hospital. In most capital cities of Australia people are in a queue and if they are pensioners they cannot get in. If the hospital thinks that a person might be terminally ill it is jolly hard indeed to get into one of those hospitals. So that is what happens to a person if that person does not get a section 3B certificate. Also a more restrictive approach was taken by the health funds after Medicare was brought in because they had $80m taken out of their reinsurance trust fund which was there to help look after the chronic cases. Therefore, they have been putting limitations on the number of days that a person's private insurance stays at a certain level.

Let us look at what happens in practice with a lot of these things. I have a number of examples. First of all I will quote from the Australian Broadcasting Corporation's World Today interview with Sheila Truswell, who is a social worker at the Royal North Shore Hospital of Sydney. She was asked:

Where do the problems start? Is it in the reclassification stage?

She answered:

There are several difficulties about it. The first is that there is no legal definition of what acute care is. So, the doctors have to fill in this certificate without clear guidelines of what they are supposed to be saying. There are penalties attached to this which are $10,000 fine or 5 years in prison . So, you can imagine that some doctors are pretty reluctant to put their names to a piece of paper which carries these sorts of penalties when there are no clear, or legal definitions as to what they are writing about. However, if the patient is having acute care, and there is no doubt about it, like somebody in the spinal injuries unit or somebody having treatment for renal failure, there is no problem. That patient is definitely still requiring acute care and the certificate is no problem.

But for the people who have been ill in the acute hospital and who need to go out, and possibly are not able to look after themselves at home, the problem is where do they go. The health funds do not cover them in the private hospitals unless they have taken out insurance and Medicare certainly does not cover people in private hospitals. It is only for people in public hospitals.

A lot of these people have dropped their private hospital insurance because this Minister for Health has suggested that, under Medicare, they should do so because they will have a bed available in a public hospital. Those beds are simply not there. Let me quote another answer given by Miss Truswell. She said:

It is very difficult for us, who are working within the system, to get exact information. It requires a great deal of researching, phoning up and trying to get the exact information. For people in the general public, it is almost impossible. There is confusion and anxiety about being ill in the first place, let alone all the bureaucratic difficulties that surround their discharge from hospital after 35 days.

I will quote now from a copy of a letter sent to the Minister, who is at the table, in February of this year. I have much later examples. I picked this one out. It was written by somebody in Sydney. I will not identify the person. It states:

I am writing to you--

this is to the Minister opposite--

regarding my mother, aged 80, to advise you of the situation I am in due to ' Medicare'. In October last year my mother was admitted to--

I will not mention the name of the hospital, but it was a private hospital in Sydney--

. . . into a six bedded ward after having had a stroke. In the first two weeks in hospital she suffered a further two strokes which has now left her paralysed down the right side, her speech is impaired and she is in a confused state of mind and is also in constant pain. She is incontinent and consequently catheterised. She also gets urinary tract infections which causes diarrhoea and she is immobile. She is in need of constant continual nursing, having to be bathed, fed, dressed and constantly turned to avoid bedsores. She was a rotund lady in October but is now frail and thin. As she has lost so much weight she can no longer wear her dentures and the paralysis makes it difficult for her to swallow and she is only able to have pureed food. The nursing care and attention at the Scottish Hospital is wonderful.

My mother is a pensioner but is still able to pay into the highest scale of the Medical Benefits Fund. Up until Medicare-1st February-the hospital accommodation has been fully insured-NOW due to lack of Government Funds to the hospitals, the closing of hospital and placing hospitals into categories for Insurance it has made it impossible for the ordinary citizen to have the privilege of being ill.

The Scottish Hospital, Category 3, has to now close its lower level for survival of the hospital due to lack of Government Funds. This is where the long term patients were. My mother now has to be moved upstairs and go into a private room, costing $145.00 per day. 3B Certificates which were issued before can no longer be issued unless it's ''Acute Care'' as opposed to before Medicare of '' continued Management for Medical Reasons''. If these 3B Certificates cannot be signed by the doctor the hospital fees will cost out of pocket $77 per day or $ 539 per week-Please Sir, where am I to find that sort of money? No one can afford that kind of money.

During all this time I have been trying desperately to find a Nursing Home. I have her name down at seven places, one of which said I would have to wait at least twelve months and another two were not interested in taking my name as the lists were too long. This situation for the patients who need ''extensive'' care in nursing is unbelievable. What is happening to the Country? At this rate we can only go backwards.

Sir, please help me-advise me what to do with my mother-where am I to place her ? Please can you find a bed in a nursing home for her or could you please tell me where I can find $539 per week to keep her in hospital? I am getting quite desperate and sick myself worrying about it.

I have a number of these letters. I have another letter concerning an 89-year- old man in Melbourne who has a heart condition and lung cancer. He is frail, unable to stand or even sit out of bed. He has been enrolled in a fund for 17 years but because of the drop in the re-insurance payments and the difficulties of section 3B certificates the son has simply got to find somewhere for his father to go. His daughter stated:

In the past five weeks I have driven many kilometres visiting nursing homes and spent many hours ringing up in an effort to find a bed for my father. Out of 20 or so nursing homes contacted only five have even been willing to place his name on an urgent waiting list-a male bed is even harder to find than a female one. One home to whom I had applied in November 1983 for a place for my father in case of emergency, informed me that he was now fourteenth on an urgent list and that it could be two years before a bed was available at their rate of vacancy.


Mr Donald Cameron —How long?


Mr CARLTON —Two years. She continues:

Others gave me eighteen months as a waiting time. Every home has told me that their lists are either lengthy or closed with many in my situation.

. . . . . .

The trauma of being continually knocked-back has to be experienced, exacerbating as it does the stress involved in having a seriously ill, loved family member. The hurt of having to continually ask for help, ultimately begging and competing with others in similar dire distress is demoralising and soul destroying.

It is not as if this has not been known for a long time. On 23 March the Brighton Committee on aged care in Melbourne wrote to me and I am sure also wrote to the Minister pointing out these things and saying that something really has to be done about it. The letter states:

The Committee is very concerned that there appears to be no acknowledgement that this problem exists or that any attempt has been made to find a satisfactory solution.

I have been raising the matter in the House and around the country over the eight months since Medicare was brought in. The Minister makes attacks on private hospitals. He made another attack today, in Question Time, on a nursing home proprietor but he does nothing to deal with the actual problem.

I will quote another problem. This is due to the fact that certificates can be revoked retrospectively. Into my office only last week came a person whose father died on 4 July 1984 after being ill in hospital over a number of months. The illness began just before Medicare came in. A section 3B certificate was issued on 1 March and 31 March and then continuously up to the time that the patient died on 4 July. On 27 August-the patient having died on 4 July-the widow received a letter from the fund saying that the first two certificates put in on 1 March and 31 March had been revoked. That meant that there was a gap of $2,069 .37 between the bill from the hospital and what was paid back by way of nursing home benefit only to the patient, but that only covered two months; there is still another four months to be dealt with. On the same average gap over the four months there will be a $6,000 bill for this widow and that of course is being applied retrospectively. The certificate is revoked retrospectively and so we have a person who is bereaved--


Dr Klugman —That is the funds.


Mr CARLTON —I do not care whether it is the fund or anybody. It is the system. It did not happen before 1 February this year. It did not happen before Medicare and the rules that the funds are governed by were set by this Minister and this Government. I am just not accepting this any longer. This is absurd and it has been absurd for eight months. Everybody knows it is absurd; even the advisers know it is absurd. There have been discussions with private hospitals and all the bodies concerned. Welfare groups and community groups have written in about it but, because it only happens to a relatively limited number of people and is not affecting a broad number of votes, the Minister has done nothing about it. It is time it came out.

We are not questioning the economics of this matter, it is obviously not a good thing to have people who do not need acute care occupying hospital beds at a higher cost. I have no quarrel with that. The economics of it are quite simple; we have heard the Minister explain them. I was aware of them when I was a Minister. I knew that this was happening, but there was absolutely no way that I would bring in a rule to throw the people out of these places or give them additional costs until I had worked out some way of dealing with them. If there is a freeze on nursing home beds-we know there is a shortage-we know there will be a problem in these cases. We know that the people concerned are at their weakest moment and yet the whole thing is brought in before this additional domiciliary care, before there is proper assessment, before the nursing home lists are reduced and before a jolly thing has been done to deal with the agony of these people. This Minister and this Government are absolutely and clearly responsible for this. It came in under Medicare. It is yet another one of the most fraudulent, cruel and nasty aspects of this wretched socialist health scheme.


Madam DEPUTY SPEAKER (Mrs Child) — Is this amendment seconded?


Mr Donald Cameron —I second the amend- ment.