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Tuesday, 13 June 1989
Page: 3857

Senator CROWLEY(3.20) —I have just listened to Senator Coulter's explanations of what the Australian Democrats are proposing to do in respect of this legislation, and I must say that I find those proposals bizarre and most offensive. I am very pleased to support this package of legislation introduced by the Government. I urge all other senators to do the same. Senator Coulter referred to two items that I particularly want to address-the problem of general practitioners and their registration and the problem of reinsurance. He commenced his remarks by saying that nowhere in our training in medical school do we learn to deal with the problems that confront general practitioners (GPs). That was just an attempt at bitty point scoring by the honourable senator. But one of the problems in medicine is that that is not taught to any doctor. Not only general practitioners but all doctors need the skill of being able to listen to patients with sympathy and understanding. In fact, one criticism that is often made against some of our specialist colleagues is that they do not seem to have the capacity to talk or listen to people. If the honourable senator wants to improve medical training by including in the medical undergraduate course such subjects as the consideration of psychological factors, this should be done not only because it might benefit GPs but also because it might be good for general practical medical care.

Senator Coulter justifies his opposition to this legislation by suggesting that some of these things were not done back in the 1950s when he was studying medicine. That seems to me to be spurious in the extreme. It may depend on which medical school he went to. I was a tutor for first year medical and nursing students at the Flinders University Faculty of Medicine from the time that medical school was established. I was involved with the human development side and I assisted students in the first and subsequent years to deal with their basic general practice associations and training. In fact, contrary to some other medical schools, the Flinders medical school took general practice and family medicine practice very seriously. For example, it dealt with community medicine in a different way from the University of Adelaide school of medicine. By way of comment on what Senator Coulter had to say, I urge caution, that general practice training--

Senator Peter Baume —Is this a tribal war?

Senator CROWLEY —No, not at all, Senator. I am actually putting some facts on the record to refute some fairly nonsense claims from our Australian Democrat spokesperson.

Senator Coulter —You misunderstood, Senator.

Senator CROWLEY —I do not misunderstand at all; indeed, I think the honourable senator does. General practice medicine has been acknowledged for a long time as a very worthy discipline. In fact, general practitioners have been fighting in a separate ballpark from the rest of their medical colleagues. Perhaps the honourable senator remembers-perhaps he does not, but I do-the effect on general practice medicine when the then Minister for Social Security, Bill Hayden, established or assisted the funding of the family medicine program. That led to a great sneering campaign-I can think of other words, but I believe they are not parliamentary-by the medical specialists at their general practitioner colleagues. They ridiculed and laughed at the general practitioners for wanting a college, for wanting to upgrade their skills and for wanting to address in-service training and ongoing postgraduate medical training for general practice, let alone the contribution that this could make to the undergraduate training of medicos.

I would have thought that in opposing this legislation Senator Coulter is actually contradicting all the things he wants to see happen. What is the possible reason for opposing the establishment of a register of general practitioners under the Royal Australian College of General Practitioners? This simply brings the College into line with other specialties in medicine. The Government has not determined this proposal; it has been done in consultation with the College. It is very similar to the set-up of other specialties. The Government is not determining who shall be a general practitioner or who shall be registered. It is saying, `We will take account of and acknowledge, as you have asked us to do, the importance of in-service training, postgraduate specialist training and the need to increase the skills of general practitioners. If you do that, we will assist in the encouragement that you want to give to the training of general practitioners by providing an increase in fees in recognition of those skills gained by general practitioners'. What possible reason does Senator Coulter have for opposing such a proposal which will do precisely what he reckons should be done? Because apparently 10 per cent or 10 to one of the letters he received were running against it in the first place, he was persuaded to go against his preferred ideas of what would be good for general practice training. I cannot understand how he can stand up in this place and oppose the recommendations in this legislation.

Many of the people who wrote arguing appallingly about the challenges and the dreadful things in this legislation had their facts wrong and they did not bother to check them out. I have a letter from the Australian Medical Association dated 9 May 1989 which deals, amongst other things, with the problem of women doctors-and I must say that the AMA writing on behalf of equal opportunity means that miracles are possible. The letter states:

The real problem for women is that in many cases they do not practise medicine full time, preferring to practise one or two sessions per week.

If they practise two sessions a week, by definition under this legislation they would qualify for registration and the higher fees. If they do not, they will continue to enjoy remuneration at the present level. Nobody is going to suffer a setback unless what the honourable senator proposes is carried through this place. Not only would the second tier not be introduced but also the 5 per cent increase to be introduced with the schedule changes in August this year will not take place.

I will be very interested to see whether the Opposition and the Democrats will say to the general practitioners of Australia, `We are minded', for reasons that are absolutely unclear, `to defer this legislation'. They will hold up the introduction of the new schedule of fees and an increase for about 90 per cent of the general practitioners in this country because they think the Senate might be able to do a little better on this than the appropriate specialist college-the Royal Australian College of General Practitioners-in consultation with the Government. It is interesting that a part of the Senate is minded to set itself above what is in this legislation, which was introduced after extensive consultation.

Senator Coulter suggests that not enough people know about this legislation. Well, many got to know, because they wrote him letters. As a doctor, I have received a letter from the Royal Australian College of General Practitioners, but I am not registered as a general practitioner. Presumably, like most of the drug companies, the College has a hit list of all the doctors in this country. I am sure that Senator Baume agrees with me-and Senator Coulter probably does, too-that we get a lot of mail because we are on various mailing lists. I got a letter telling me what the Royal Australian College of General Practitioners preferred in this area, what it had done, how extensively it had talked and how it had written to every doctor involved. It is not correct to say that aspects of this whole matter have not been raised with the doctors of this country. It is interesting to note why, with all that information, a campaign has slowly been mounted to oppose the legislation. What possible objection can there be to a register of general practitioners which will be handled through their own College? What possible objection can there be for an acknowledgment-as this legislation does-of the benefits of in-service training, improved skills and the development of general practitioners? What possible objection can honourable senators have to the acknowledgment of increased skills by giving the incentive of increased medical rebates? I just do not understand what his case is. There is no logic to it. He must be running interference for the AMA or some subset of doctors who have persuaded him to think peculiarly.

If the honourable senator has some difficulty with the definition and if he had stood up and said something about that, I might have said, `Well, you might have a case until we sort it out-I have spoken to the Department and to the people involved and I think there are minimal difficulties'. Anyhow, even if there are difficulties, they are the sorts of things that the College, and the independent group set up to look after this, will be able to sort out in due course. Does the honourable senator really want to say that the whole thing should be held up, that all GPs in this country should be dudded of an increase in their remuneration, let alone advised that they will not be able to make up their own minds and that it would be better for the Senate to do it for them? I think that would be offensive in the extreme to the professional status of the College and the general practitioners as well as those people in the Department of Community Services and Health who have worked this through.

The ACTING DEPUTY PRESIDENT (Senator Crichton-Browne) —Senator Crowley, the Chair is also very interested in this subject. Would you be gracious enough to direct your remarks through the Chair?

Senator CROWLEY —Certainly, Mr Acting Deputy President. I am sorry if you have not been able to hear. Time constraints prevent me from running through all the arguments. However, Senator Coulter in particular has talked from time to time about the importance of concern for patients. It is the patients themselves, particularly the elderly, who are concerned about the effect of the delay or defeat of this legislation on general practice registration and consequential changes in fees. That would make a difference in terms of remuneration to doctors. A lot of elderly folk who seek to see their doctors may still be charged under the time arrangement instead of under the professional competence arrangement which is proposed under this legislation-that is, the second tier of remuneration. It also means that doctors may be encouraged to cease bulkbilling, at least to some extent. The increased remuneration would acknowledge the contribution of general practitioners in this society. It would also acknowledge their contribution financially and assist them in continuing to bulkbill, as I believe something like 60 per cent of services through general practice are currently bulkbilled. From the practitioners' and the college's point of view, from a recognition of the professional competence and independence of the College of General Practitioners and what is best in terms of care for patients, I cannot see how anybody would want to oppose the legislation. I am totally unpersuaded by the arguments that Senator Coulter put up.

Before I make some comments on reinsurance, I allude briefly to Senator Boswell's motion which seeks to alter the terms of reference of the inquiry by the Senate Standing Committee on Community Affairs. I am advised by the Chairperson of that Committee that the terms of reference have not yet been brought to her attention, which I think is offensive in the extreme. I believe that the Opposition has discussed them with the Australian Democrats. The Democrats would not support the terms of reference when seven or 10 points were included, but now they have been reduced to four the Democrats think there may be some mileage in it. Again, I do not know why when many of the points raised and the areas floated by Senator Boswell were covered in the Senate Committee's inquiry into nursing homes and hospitals. Senator Walters would have to agree that at that time we looked at the problems of people with disability who found themselves in nursing homes that provided care for a whole range of people. We appreciated then and commented in our report that that was a less than optimal way of attending to the accommodation needs of people with disability. The disability legislation has taken up some of these issues and is dealing with them. It is quite retrograde to ask the Senate Committee to take on this reference in some ways yet again. As we are also dealing with a specific term of reference going to the employment of people with disability, I do not see that we should extend it to housing, particularly as much has already been said about it by the Standing Committee dealing with it.

When I became a senator I was advised that standing committees' terms of reference were the business of government. Since I have been on the Senate Standing Committee on Community Affairs, we have had nothing but references dumped on us by the Opposition, in cahoots with the Democrats-sometimes because the Democrats want a royal commission and people will not go that far, and in this case because people want to run interference on behalf of the disability legislation. They are not seriously inquiring into this area; they are just making a problem for government. Now people are requiring the Senate Committee to take references as a kind of motion to the legislation. That is not the appropriate way to deal with the legislation. Opposition members should support it or defeat it; they should not muck around.

Senator Knowles —You never attend. Why do you worry?

Senator CROWLEY —You really are puerile.

Senator Knowles —Ah, you cannot deny it, can you?

Senator CROWLEY —Indeed I can, but I am not about to cross the chamber on puerile matters.

The ACTING DEPUTY PRESIDENT (Senator Crichton-Browne) —Order! I ask Senator Crowley to direct her remarks through the Chair.

Senator CROWLEY —Senator Knowles is puerile in her comments, Mr Acting Deputy President, and I beg your pardon for directing that comment across the chamber. I do not think that I should take up puerile issues. I will turn briefly to the matter of reinsurance, which is a problem for the Opposition. Page 3281 of the House of Representatives Hansard of 31 May 1989 records Dr Blewett, at the beginning of his answer to a question by Mrs Harvey, as saying:

I welcome the Opposition's decision to support the Government's reforms in the reinsurance area, particularly its response to the concerns of many of the aged in this community . . .

Yet I came into this place today and heard Senator Puplick going on about how reinsurance, I was given to believe, is not something he wants to support.

Senator Alston —What? Blewett speaks on behalf of the Opposition, does he? Does Blewett speak on behalf of the Opposition?

Senator CROWLEY —He was welcoming the Opposition's decision to support the Government's reforms. I would suggest that that was because he had negotiated with the Opposition in the House of Representatives.

Senator Alston —Why should you assume that?

Senator CROWLEY —Through you, Mr Acting Deputy President, I say to the Opposition that it seems quite clear that what happens on the Opposition benches in the House of Representatives seems not to be transmitted to the Opposition in the Senate. Again, I do not quite understand why the Democrats would want to oppose this. I have heard the word `bandaid' used, but that is a very unfair reading of the aims of the legislation in terms of reinsurance. The legislation supports and develops the community rating principle and that is something we must keep in mind. What the Government proposes-and this is after consultation with the industry and with the support of most of the industry-is that the community rating principle will apply and everybody in the private insurance industry and health area will pick up some contribution to the cost of insuring people who are either elderly or chronically ill. Both of those categories of people are the areas that make the largest and most expensive claims against health insurance. If we want the health insurance industry to survive and to be able to provide extra care and support for people through the private insurance pool, we must also make the costs manageable, affordable and equitable not only for those in the community who buy the insurance but also for those within the insurance industry. It is unreasonable to expect some of the older, more established insurance firms to pick up in large cost the insurance of elderly people, particularly those who either become elderly over the years of insurance with that organisation or join because they know they will get that kind of coverage.

It is important to support the principle of reinsurance. Anybody who argues that the proposal is just a bandaid measure does not appreciate that it continues the principles on which the whole private insurance industry vis-a-vis the Government has been negotiating and has been established since the Government came to office. The Opposition seems to object to it and I do not know why. Does the Opposition suggest that there should not be a community rating? Does it suggest that people should buy insurance according to their means? Does it suggest that there should be front-end deductibles or that people who are well should take the risk of not being insured? Does it suggest that this is just another means by which, one way or another, we can have yet another committee with which it can kick Medicare to death? Does the Opposition remember why Medicare was established? It was established to cover some two million Australians who were not insured and who are now covered. If the Opposition would do away with Medicare, if it has some kind of divine plan in the private insurance area, would it please make it clear so we can look at it and argue to the community what the Opposition really means? Would the Opposition say to people who as individuals on about $9,500 are exempt from the 1.25 per cent-or is it 1.5?-Medicare levy--

Senator Alston —You don't even know.

Senator CROWLEY —No, I have suddenly forgotten. Can Senator Alston help me?

Senator Alston —It is 1.25.

Senator CROWLEY —I thank Senator Alston. Would the Opposition say to those singles whose income is below about $9,500 that they should pay or risk being uninsured? Would it say to a couple with no children and whose income is about $16,000 that they should have to buy insurance or risk being uninsured? Would the Opposition say to those people who have children, whose exemption on family income increases by $2,300 or thereabouts each year per child, `We will do away with Medicare. You can buy private insurance or you can risk being uninsured.'? Does the Opposition seriously argue that we should go back to pre-Medicare days when people could not afford insurance and took the risk of being outside it because of the prices-the inequity in costing?

One of the things the Opposition has to deal with is the fact that Medicare is in place and has benefited those two million people, plus many thousands of other Australians; they make a choice and they have made their choices clear. Private insurance, as a percentage, has settled down to just below 50 per cent. That is how many people insure privately now. The others say, `Thank you very much. The adequate health care we get through our general practitioner and our public hospitals will do us fine'.

Senator Knowles —What about the waiting lists?

Senator CROWLEY —I will come back to them. It makes no difference talking to Senator Knowles. She hears nothing and learns nothing. When we talk about the quality of medical care in this country we should be very proud. Our public hospital system is excellent, and our general practice and provision of specialist medical care around this country is something that we should be proud of, not something that we kick to death as the Opposition does.

From time to time, of course, there are problems. We acknowledge that. I advert to the hospital waiting lists, which seem to be the only thing on which Senator Knowles can focus attention. They are the only things she can find to criticise. A number of points need to be made. The first is that waiting lists are essentially in the hands of doctors, not hospitals. They depend upon whom doctors list for surgery, elective surgery in particular. We all know that people who need emergency care in this country get it. We also know that people who have coronary operations or need intensive care do not go to private hospitals for the large part. They go to the public hospital system because that is where the quality medical care in this country is provided. The demands on the public hospital system are extensive. We have had it argued at length in this place that the increased demands on the public hospital system depend on a number of causes which are not easily addressed.

The causes concern the increase in high technology developments in medical care. People who are able to have hip or knee replacements can enjoy that kind of care. They will take that opportunity, and their doctors will urge them to take it, making their lives healthier, happier, and free of pain, at least in large part. There are many other high-tech developments in the medical area that put special strains on the use of public hospital facilities. On a few occasions negotiations have enabled such facilities to be provided in the private hospital system, provided the assistance for that technology is approved by a committee which examines the need for, and the proper distribution of, such high-tech services.

The other causes of demands made on hospital services have been addressed on a number of occasions. In fact, the Federal Government, in recognition of those difficulties has agreed with State Ministers for health, and is already putting money in place, to assist the State governments in addressing the problems of demand on their public hospitals and those waiting lists. I hope there will continue to be-and, under this Government, I have no reason to think otherwise-imaginative solutions proposed to the challenges of delivering the comprehensive and very good medical care that we have known throughout this country.

We also know there are some areas where people do not have access to the same excellent service. For example, sometimes people in rural or isolated areas do not have immediate access to the same quality of care as people living in metropolitan cities around Australia. That is also addressed under the general practice proposals, where the hospital provision of services by medical practitioners in rural areas will be accredited towards their general practice skills and development. So in some ways, through the general practice registration and the changes proposed in that area of health, the provision of medical care in the country will continue to try to meet the requirements of an adequate service with a level of skills in medical care which matches as far as possible what is provided in our major urban areas.

I do not believe the reinsurance principles can be opposed. The Government is seriously addressing the way in which we can have the best equity in the health reinsurance area. The Government also has letters and press releases from Australian pensioners and the Australian Council on the Ageing, saying that they strongly urge the support of this legislation to allow the reinsurance proposals to go through. I do not understand why the Opposition continues to oppose these very reasonable, comprehensive and modest changes under the Community Services and Health Legislation Amendment Bill. These changes have been examined by a wide range of people who will be affected. They have been developed after deliberate and serious consultation with the people involved. They meet the proper requirements of what is proposed under the legislation, giving a definition of a general practitioner; acknowledging the importance of postgraduate in-service training, and providing a financial incentive to support that principle and encourage it. We have received approval for the reinsurance proposals from pensioners and chronically ill people. They know the proposals will enable them to buy private insurance because the costs will be shared by a number of companies and able to be kept modest and in check.

As far as the disability legislation is concerned, I simply make the comment that it is peculiar that the Opposition, instead of opposing the legislation, has moved a motion for a reference, yet again, to a Senate select committee without approaching the chairperson of such a committee, let alone anybody else. That is a very inefficient way to tackle legislation. I do not believe the proposals in this legislation will disadvantage people, and I do not believe a Senate select committee will provide more information to improve what is proposed under this legislation.

Finally, I urge those people who think a Senate committee inquiry into general practitioner fees will be the way to parousia, let alone a better answer, to rethink. The costs to general practitioners around the country will be extensive indeed. The increased payments to general practitioners amounting, on estimate, to $15,000 a year, will be deferred, if not denied, for many months. The definitions-which seem to be at issue, rather than the substance of the legislation-will not necessarily be improved by asking a Senate committee to take over the role of the college in consultation with government. I think it is arrogant in the extreme to suggest that is the better way to go. If the problems are only definitional, that should have been the substance of Senator Coulter's objections rather than historical references to the time when he was at school. I do not believe there is any substance in the Opposition's criticisms of any of the proposals under this legislation. I will be interested to hear what other arguments-spurious as they will be-the Opposition mounts to convince me otherwise.