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Tuesday, 13 June 1989
Page: 3871

Senator PETER BAUME(4.37) —This debate is an opportunity to review where we are with health policy, to examine what the Government is doing and whether some of the initiatives make sense. The Community Services and Health Legislation Amendment Bill 1989, the main Bill in this package, brings together several disparate propositions. When the Bill was first put up for debate the House of Representatives had risen and we did not think it was returning. At that point we were faced with the usual element of legislative blackmail: the proposal that either we support the Bill or the good parts could not come into operation. There is not too much point in complaining about that. We did it when we were in government; Labor does it when it is in government. It simply reflects the arrogance, incompetence and lack of feeling for parliament and the requirements of the parliamentary process that characterise government and some elements within the Public Service. Of course, the House of Representatives is now coming back, even if only for one day. We can therefore give this legislation the attention it warrants and deserves. If there are amendments the Bill can be returned to the other place and dealt with there.

One could reflect that anyone listening to this debate here, in the other place or in the wider community may have wondered, been bemused or been a bit confused by the concentration on questions of money-on dollar inputs-as if dollar inputs in medical services, of themselves, had anything to do with the health outcomes. It is a reflection of the intellectual poverty of the so-called health debate that it is about cash inputs only, about power relationships or about service provision and payment for service provision, and not really about what is achieved in health.

It is worth reflecting on the health goals of the Government. One of the advantages of program budgeting is that each year we receive from the Department of Community Services and Health a set of explanatory notes which contain in them some statements of departmental mission, some statements of purpose and objectives. Some goals on health set out in the documents presented to the Estimates committees are available. The kinds of goals to which the Government addresses itself in those documents include improving the health and well-being of the Australian community. We can judge what is being proposed today by whether it helps to achieve that goal. Does it improve health; does it promote good health and reduce illness? It is not a question of whether we are paying for more things more efficiently. It is a question of whether this legislation has any relationship to the goals laid out in the explanatory notes of the Community Services and Health portfolio-the Government's own notes, its own goals and objectives, against which we are entitled to evaluate what is proposed in this legislation.

The onus is on the Government and on Government senators to establish, if they can, some direct relationship between cash subsidies, money inputs, co-payment arrangements, medical benefits rebates systems and any measure of health. The Government has to tell us why paying differently makes people healthier. That is the goal it has identified in its documents and we would like to relate what the Government is proposing in this legislation to those goals. In the jargon of evaluation practice, do the inputs which are provided, the structures which are used and the process arrangements have anything at all to do with the health outcomes which are supposed-not only by the naive and the simple-minded like me-to underpin and to justify the whole medical service financing structure? The Government should tell us why paying more or less affects the health outcomes of this country in terms of what we get by way of better health. In discussion of the outcomes that occur, this debate has been awful and the contributions of Ministers in their second reading speeches have done little to add to it. It should be about better health, or else it is a con.

It is possible that the low level of the health debate reflects ignorance rather than malice-I am willing to acknowledge that. Yet there is so much to which we could have pointed in presenting this legislation. For example, we know that there has been a major improvement in the outcomes in Australia for the last decade or so for ischaemic heart disease-what the public calls heart attacks. It should be a proper and necessary task for a parliament to ask itself the obvious question: why have these outcomes improved? What has led to improved outcomes, to lower mortality and to better results in relation to ischaemic heart disease? What can we learn from our success in this area which we can now apply more widely? What might we wish to do differently, based on what has improved? It is not an irrelevant question and one would have hoped that the Department of Community Services and Health would have presented an omnibus Bill that had something to do with health.

A colleague skilled in these matters has concluded that some of the improvement in ischaemic heart disease has come from better drug therapy for high blood pressure, improved high technology interventions such as coronary artery angiography and coronary artery bypass surgery and lifestyle changes such as better diet, more exercise and less smoking. One would have expected that governments would grab on to that information, that they would concentrate subsidy and assistance on those things which actually work. We know that there has been an improvement in coronary artery disease outcomes. We know now what causes it-lifestyle changes, drugs for blood pressure and certain high technology interventions such as coronary artery surgery. We would have thought that the Government might have concentrated more subsidy and assistance on those things which work even if it meant removing subsidy from other areas which do not work. We might have thought that it would have meant better access to certain drugs, better access to coronary artery angiography, or better access to coronary artery surgery when that was needed. I cannot forget, neither can my colleague, Senator Puplick, that one of our political heroes, John Clarkson Maddison, died while waiting for a coronary artery bypass operation. He probably died unnecessarily. We are not going to forget that. We know that this intervention works. We would have expected better access to it if the Government were impressed by the outcomes, but this Government is either mad or bad.

Senator Patterson —It could be both.

Senator PETER BAUME —It could be both. This Government has made more expensive and more difficult the access to certain drugs which help produce these better outcomes. We had a not very edifying debate about a year ago in this place in which we tried to stop the Government's attempts to remove access to these drugs. The Government has limited its support for high technology interventions and it has provided too little support to lifestyle changes. What has been provided to support the lifestyle changes-anti-smoking, better diet and more exercise-is absolutely pathetic, especially when those changes might require the Government to put itself into conflict with powerful commercial interests. I say to the Government, `It is hard the first time, but the more often you put yourself into conflict with the commercial interests, the easier it gets'.

Meanwhile, the debate about money and power goes on as if it is a debate about health. This Bill is just another episode. Since this is a debate about subsidy, money, support and co-payments, let us look at some of the critical figures and some of the critical data. First, the level of our gross domestic product (GDP) devoted to providing medical and associated services has not altered a lot in spite of the Government's claim one way and critics' claims the other. Rises in expenditure by government seem to have followed more or less the rise in GDP and have been less than the rises in average weekly earnings in recent years. Further, the share of GDP going to the medical services sector has been constant. One year it was 8 per cent, but it has been constant mostly at about 7.5 per cent to 7.8 per cent, and the figure in 1985 was actually 7.5 per cent of GDP. I have a table from the Department's book entitled Australian Health Expenditure which sets the total health expenditure as a percentage of GDP from 1970-71 to 1985-86. I seek leave to have that table incorporated in Hansard. I have already shown it to Senator Bolkus.

Leave granted.

The table read as follows-


1970-71 TO 1985-86







1970-71 ...



1971-72 ...



1972-73 ...



1973-74 ...



1974-75 ...



1975-76 ...



1976-77 ...



1977-78 ...



1978-79 ...



1979-80 ...



1980-81 ...



1981-82 ...



1982-83 ...



1983-84 ...



1984-85 ...



1985-86 ...



1. Sources: 1970-71 to 1981-82; Australian Health Expenditure 1979-80 Australian Institute of Health, October 1985. p. 8 1983-84 to 1984-85; Australian Health Expenditure 1982-83 to AHI Information Bulletin No. 2, May 1987. 1985-86; Australia's Health, AIH 1988.

Senator PETER BAUME —I thank the Senate. If one examines the health expenditure of a number of developed countries over 15 years, one sees that it is not possible to say that our expenditures have leapt ahead or, to use a phrase, `have blown out' compared with some of those other countries. To make that point, I seek leave to have a diagram incorporated in Hansard-it is acceptable to Hansard and has been shown to Senator Bolkus-which makes this international comparison clear.

Leave granted.

The document read as follows-

Senator PETER BAUME —I thank the Senate. Further, hospital costs have not risen significantly during that period as a percentage of the total. This point is worth dwelling on for just a moment. It does not reflect complete credit on governments obsessed with accounting rather than with the needs of people. I will explain: if the number of aged people in our population is increasing, as it is, and if we accept, as we must, that age brings with it increasing morbidity, perhaps we should be demanding that hospital costs do increase significantly in real terms to keep pace with the increasing needs of the more dependent-in this case, the aged members of our society.

It depends on what our goals are. If the goals are financial-honourable senators all know the argument that all expenditure is bad and the only good government expenditure is minimal government expenditure-then we will continue to hold costs even while the target population increases, even while specific social need increases and even while the policies, particularly the policies of this Government, effectively increase the barriers to access to the services which do exist.

If on the other hand our purpose is, as mine is, to provide care where it is needed and access to care to some agreed standard, even to a modest standard, where that is needed, then we should want to increase our expenditures at least in line with demographic changes in our society. If there are more aged people-and that means more cataracts, more enlarged prostates, and more hips needing replacement-we should be providing extra services. This explains to some extent why we hear so many complaints from so many constituents about waiting lists and a lack of services.

We know that waiting lists are fallacious measures to some extent. They reflect some measure of illness and pathology decisions. As I said, if there are more elderly people there are more cataracts, more prostate operations needed and more hips needing replacement. But waiting lists also reflect the decisions of doctors about pathology-I am not criticising those decisions-and there is always some element of double counting in waiting list figures. I have seen estimates that it is as high as 25 per cent. However, I utter a word of caution. If we are having a serious debate and if we want those who understand these matters to take us seriously, we should acknowledge that in this country the essential statistics for making judgments about health are lacking. It is a great pity that only the Commonwealth, via the Health Insurance Commission, has until now had adequate information to tell us about the outcomes we are achieving in health.

The situation is much more complicated than some people seem to comprehend. For example, no one seems to want to tell us how hospital moneys might have been redistributed away from patients towards higher staff payments. This happened with award decisions which were made in favour of nursing and medical providers-long overdue decisions. However necessary or just such a series of decisions might have been, it is still relevant to our understanding of what resource division within a rigid budget cap is doing to people. If there is only the same amount of money in relative terms and more of it is going to the staff, then less of it is going to running the hospitals day to day.

In any event, it seems that the funding of hospitals has always been badly based. It has been based merely on incremental additions to historical accounting. It has not been made on any more rational basis. That is still the case. Hospitals are not responsible or answerable for service provision. They are less accountable for what they achieve in terms of access to services in their area than they are to the accountants who insist that they operate within a budget cap. They are more accountable to the accountants and less accountable to the community. That is madness.

Enough of this more general comment. I would like to mention a few parts of the legislation. Let us start with the proposed changes to pathology funding. There is a continuing matter of concern and principle. The principle is: What decisions will we make in the future to underwrite at public expense new pathology products or practices? It is not adequate to say that there will be automatic funding of all pathology services at all times for all people, whatever is introduced. The question of subsidy, of co-payment, has to involve the paymaster as well as the person who orders the tests and the person for whom they are done. Answering that question is not simple. The paymaster, after all, is the public.

Let us ask: Are we improving health outcomes with new tests or with new technology? I have already mentioned that with coronary artery angiography we think we can answer yes to that question. But we cannot always answer it with a yes. Unless we can demonstrate better outcomes, the question of subsidy is at least open to argument. It is not a question of limiting the right of doctors to offer or to order or to charge for tests. It is simply a question of the conditions under which public co-payment will be undertaken by the Commonwealth. We cannot be pathological Luddites. Progress in pathology is not about to cease. New tests are always emerging. But if the only outcome for health is marginal gain at large cost, the public interest might better be served if the subsidy were to be directed elsewhere. If there is a continuing acceptance by all concerned of the justice of the cost-benefit approach, or of program budgeting-as in government departments-that will be a gain in itself. We can use that approach for pathology services just as we can for the evaluation of any other payment anywhere else in the government system.

Not only that, but some other major advances in pathology technology are almost upon us which might allow more product at less cost and even at less rebate, perhaps with no reduction in profit or income for the pathologist. I mention only dry cell chemistry, which might eventually be such an advance. In that and similar circumstances there will need to be a continuing re-examination of the quantum of subsidy for particular tests. We do not oppose the Government's proposals in this Bill in this area.

In considering this Bill, let us consider for a moment the new approach proposed for the remuneration of general practitioners, which has been mentioned by other speakers in this debate. The Government proposes the certification of those with special skills in general practice in much the same way as Senator Walters's husband has been certified as having special skills in obstetrics and gynaecology and as some of us-Senator Sheil and I-have been certified as having special skills in internal medicine. The proposal provides for some contentious administrative arrangements-some faulty administrative arrangements, I think. They have been addressed by my colleague Senator Puplick and by some of my other colleagues. There are some other problems in what has been proposed. The proposal will also mean higher rebates for those who are certified.

The fee for service system we use to rebate doctors is truly Gortonian in its history, its genesis and its concept. It derives from the old $5 Gorton pronouncement. As a concept it is post-Nimmo and circa 1970. We should remember that as we approach the 1990s. Any system is capable of being rethought and might benefit from a new approach-even this one. While ever the old system remains yet medical practice continues to alter, while ever some doctors continue to improve and extend their professional skills and other doctors do not, the system will become more difficult to operate and less rational as a totality.

The system warrants our examining it with a view to recasting it. We can ask whose interests we need to serve. Is it the interests of the community-those of us who will be sick and who will need care-or just the interests of the providers? It is not an either/or question. We in the Parliament are duty-bound to concern ourselves first with the community interests, if we can determine what that is, and if we can work out how best to pursue it. We would hope that we could marry within one arrangement the interests of the consumers of services with the interests of the providers. There can be no questioning of the fact that general practice remains the basis of the delivery of most medical services in Australia. Sadly, the question in this Bill of greater rebates for those practitioners certified by the College has degenerated into a battle for power between the Australian Medical Association (AMA) and the College. That is not necessarily good if we are looking at the interests of health services consumers.

Honourable senators will remember that the AMA has always represented doctors in fee negotiations with government, at least until very recently when it withdrew. The College played an academic role only, at least until recently when it also got involved in fee negotiation. It is interesting that, coincidentally with the arrival of Dr Bruce Shepherd on the political scene as a major player, the AMA refused to continue to negotiate fees for rebates with government. The two events are probably not connected, but a vacuum was created. The College has moved to fill the vacuum by negotiating these new fees. Of course the AMA should return to play its traditional role as chief fee negotiator with government on behalf of the profession. It will do so better if it abandons some of the current overblown rhetoric and perhaps reflects more of Bryce Phillips and less of Bruce Shepherd, and gets back to dealing with the paymaster, whoever the paymaster is, on behalf of its membership. By its membership I mean those of us who pay our subscriptions to belong to the AMA.

Medical incomes, after all, are based on two things: fees and rate of throughput. While the arguments rage about who will and who will not get access to the new higher rebates, the fact remains that the time taken for each consultation will at the end of the day still determine the income of each individual doctor. We do not want to bring about a situation where doctors are taking less time for each consultation because of economic pressure. Hopefully, we will examine this matter in the Select Committee. Senators will try to hear the views of all, to be fair and wise, if that is possible, and to advise the Senate in double quick time so that the scheme, in some amended form, can be started. It has to be brought back with its faults remedied, its injustices removed and its inconsistencies and intrusions overcome.

My colleague Senator Walters drew attention to some of the worst features of the proposals and some of the things that are missing. We have to get those fixed. Let us work towards upgrading continuously the professional skills of medical practitioners. Let us not pretend that doctors are now prepared ideally and that medical school prepares someone adequately for family practice. Let us not pretend either or expect that doctors should just become reactive prescribers. They should still remain consultants, listening to people and responding to each person individually.

Honourable senators might be aware of some recent criticism of the lack of basic skills on the part of young medical graduates by the new professor of orthopaedic surgery at the University of Western Australia. Professor Jerzy Sikorski found that certain simple orthopaedic problems such as sprains could not be assessed or treated by new graduates. His observations are important because they highlight the importance of prolonged and adequate training to turn basic undifferentiated medical graduates into skilled family doctors. Let us do our part to improve and reward the holistic skills of doctors, if not with the present proposal, which seems flawed, with some variant of it, after more mature consultation and consideration and possibly with different detail if it emerges that different detail is needed.

Another element in the legislation relates to day surgery and to payments relating to day surgery. I want only to say that the issue here is one of subsidy and money. There is no question of principle. The issue at hand is that the Government has not consulted with the parties involved about the changes it wishes to introduce. Until that has been done adequately we do not intend to support the proposals. We do support the greater use of day surgery facilities but we want more discussion with the National Day Surgery Advisory Committee. We will vote accordingly at the appropriate stage of the Bill.

I have a few moments to discuss the new proposals for the reinsurance pool. These are simply proposals to require certain health funds to contribute more than they do now to the reinsurance pool, which will share the cost of some of the worst risks in order to relieve some of the burden on certain other funds. We know that people take private health cover because Medicare does not deliver on its goal to provide `access for all according to need, funded by all according to means'. Medicare cannot guarantee access to all. It is not funded from its contributors. The whole proposal before us makes a mockery of any pretence that there is a free market in health insurance.

Let us consider ourselves to be the users and consumers of health services. We know that 80 per cent of hospital and major medical costs are incurred in the last year of life. None of us knows exactly when our last year of life will be but it will apply to us just as it applies to other people. The fact remains that in New South Wales-perhaps not in Victoria or Queensland-when faced with a serious illness, as with most other people, I would opt for the public teaching hospital if I had the choice. In Sydney that choice would be qualified by support for the Sydney Adventist Hospital or for St Vincents Private Hospital, which are first class private institutions. But it is generally a valid theory that if we were sick enough we would want to go to a major hospital. People such as me want to go where the care is best. The problem in my State is that the private hospital system is not at present good enough to provide a real challenge to the public hospital system. I would like it to be; I wish it would be. It does not provide the challenge that private education does to the public school system. People insure privately for two things-a choice of doctor and better hotel facilities. But at the end of the day we want the best care. We can do without the other characteristics-choice of doctor or a good hotel-if the quality of care is markedly better.

The trouble is that as more and more people are forced out of health insurance the system becomes unsustainable. There is a myth about community rating. It is a myth that has existed ever since the special account was abolished early in the 1970s. That special account, which provided public funding for the uninsurable groups in our society, made health insurance viable. Without that and without adequate reinsurance it is not viable.

There are many other things I could say about this legislation. I remind the Government of its own goals. They are to ensure that people have access to necessary health services, to promote better health and to ensure that all Australians have access to necessary health services at reasonable costs. On these tests the Government's own goals, the Government's own boasts, the Government's policies, are failing to deliver. They are policies about money and they are quite inadequate. The Opposition will assist the Government in proposing these committee references. I hope the Government will accept them in good order. Our criticisms are valid and important. We will force the attention of the Government to our concerns today and in the Select Committee. I believe that we will do a real service to the community.