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Tuesday, 13 June 1989
Page: 3878

Senator PATTERSON(5.06) —As is usual under this Government we are debating cognately Bills which cover a broad range of areas. In one Bill we are debating pathology, day surgery, health reinsurance and a vocational register for general practitioners. In the other Bills we are debating changes to residential arrangements for the aged, disabled and homeless. Each of these matters is so important that I would have liked to address each in detail but time and the way the Government mishandles its business preclude me from doing this.

I must make some comment on the proposals for changes to aged care hostels and funding for those hostels. The Government clearly intends that the number of aged people in nursing homes decline and those in hostels increase. Its policy is such that there will be an increase in the dependency of hostel residents with more category 4 and, especially, category 5 residents going into hostels. The Government has recognised this in the information sheets that it provides to applicants seeking approval to operate Commonwealth subsidised hostels and nursing homes. That document states:

At present hostels cater for residents of varying levels of dependence. However it is anticipated that the proportion of hostel residents requiring personal care services such as assistance with bathing, toileting, dressing and mobility will rise in the future . . . Funding incentives have been built into the program to take account of the change.

However, there seems to be no recognition that these increasing dependency levels will also mean that changes must be made in the physical layout of hostels. It is not good enough to let hostel residents walk long distances through exposed walkways-to me, coming from Melbourne, that means exposed walkways in the freezing cold-to have their dinner. I have seen this situation in more than one hostel. I do not know how many hostels the public servants have visited but, if the number of nursing homes they have visited is any indication, I presume that not many of them have seen the sorts of facilities that are operating where residents have to walk these long distances and where managers of the hostels have told me that the residents are almost frozen by the time they get to dinner. There are no funds for taking the meals to their rooms. Unless we can modify the hostels and the arrangements and maybe even get some funding for meals to be delivered to rooms for residents who are not well, this system will not work. The price we will pay if we do not do this will be the deterioration of the health status of hostel residents and an increase on demand in our nursing home places.

The Liberal and National parties object to the changes in the Community Services and Health Legislation Amendment Bill 1989 affecting private health insurance because they are a quick fix solution. The proposal will not provide a long term solution to the problem of increasing rates and will not safeguard the health care interests of elderly Australians. The problems in the health care industry have arisen, firstly, due to an ailing Medicare system that provides no incentive and no reward for belonging to a private health fund. A declining proportion of the population is privately insured. Currently, that proportion stands at 45 per cent compared with 61.5 per cent when this Government came into office. This is exacerbated by the fact that it is the young and healthy who are dropping out of private health insurance.

Secondly, the problems are due to the fact that the Labor Government has not been, and is not committed to, supporting the reinsurance trust account, which is the means by which the cost of health insurance for the aged and chronically ill is spread over all health funds. We have heard a lot of rhetoric from the Hawke Government telling us that it is committed to community rating and the reinsurance account. If the Government believes that community rating and reinsurance are the way to go, why has it withdrawn its support for the reinsurance pool to the tune of a cumulative $450m over the past five years? This one-off $20m injection that the Government is now offering is an opiate fix which will relieve the pain in the short term but will not cure the underlying chronic disease.

The Liberal and National parties will allow part 4 of the Bill to pass, but we recognise this as only a quick fix solution, and we have recommended that a Senate select committee be set up to look into the long term arrangements of the health insurance industry. The amendments in part 3 of the Community Services and Health Legislation Amendment Bill allow for the introduction of a vocational register for general practitioners (GPs). The requirement for general practitioners to remain on the register is that they undertake continuing medical education and quality assurance programs accredited by the Royal Australian College of General Practitioners (RACGP). It also allows for the introduction of a two-tier system of rebates, and an audit and monitoring procedure to be undertaken by an independent peer review organisation-so independent that it would appear from the documents which I have received that `the nominees of the RACGP, will constitute a majority of votes on the board'. So much for independence. How can this Senate be expected to support this legislation when details of the audit and monitoring procedures have not been formally communicated to us by the Minister for Community Services and Health (Dr Blewett)? I ask the Minister for Justice, Senator Tate, who is on duty, whether it would be possible for the Senate to receive formally details of the auditing and monitoring procedures, because this is an important part of this legislation. We need to know what is involved.

Last year, the Committee of Inquiry into Medical Education and Medical Workforce, chaired by Professor Doherty, examined over 400 submissions. Among the many recommendations put forward by that Committee were a number aimed at enhancing the new registered practitioner's preparation for general practice. I seek leave to incorporate into Hansard the relevant section of the executive summary pertaining to this.

Leave granted.

The summary read as follows-

The Committee sees particular importance in the design of curricula that would give students the knowledge, attitudes and skills needed to meet new challenges during a professional lifetime. [5.4.7] It supports greater emphasis than is currently shown in several medical schools in undergraduate training in general practice, and recommends that:

5 (iii) Medical schools aim to provide exposure to general practice, early in the course as well as providing at least a month's block experience in general practices or community health centres late in the course. [5.4.2]

The Committee recognises that serious resource constraints on the tertiary education sector have restricted undergraduate programs. It realises that allocation of funds to universities and within universities is influenced by many factors outside its terms of reference. It does however recommend action by the Commonwealth Government on two matters: practical training for general practice and the recruitment of suitably qualified staff. [5.4.2, 5.7.2, 5.8]

The Committee notes the shortage of resources available for the teaching of general practice and recommends that:

5 (iv) The Commonwealth Government provide grants to match university allocations to ensure that at least $1000 (in 1987 dollars) per student in the final year of the course is available each year for placement and supervision of students in general practice and community health centres.

In making this recommendation the Committee recognises that university departments of general practice will find that the additional funds can be best utilised in various ways according to local circumstances, and may allow the development of model university teaching general practices as well as better utilisation of community health centres for teaching. [7.3.5]

The Committee (with one member dissenting) expresses concern at the impact on the recruitment and retention of academic staff, and hence on the quality of medical school teaching and research, of disparities in remuneration flowing from recent industrial awards for part-time and full-time hospital staff in several States. It draws this concern to the attention of relevant State and Commonwealth Government departments and teaching hospitals, and on a majority vote of 6:1 recommends that:

5 (v) A working party of bodies involved in the employment of clinical academics in teaching hospitals, including State Departments of Health, teaching hospitals, universities, and the National Board of Employment, Education and Training, be established as a matter of urgency to seek approaches to the problem of significant salary disparities between clinical academics employed by universities and specialist medical staff employed by hospitals.

It also recommends by similar majority vote that:

5 (vi) The National Board set up an appropriate working party to review salary discrepancies and other influences on recruitment of academic staff, including medically qualified staff, to preclinical and paraclinical departments in making recommendations that the working party should take note of any effect on salary relativities of recommendations by the working party proposed in recommendation 5 (v).

Senator PATTERSON —I thank the Senate. The Committee also recommended that all Australian States and Territories require graduates to undertake a second pre-registration year. It also said that it believed:

That the incorporation of general practice experience into the preregistration period will be advantageous to all practitioners whether they become general practitioners or specialists and will contribute to recruitment to general practice.

I seek leave to incorporate in Hansard recommendations 6 (iv) and 6 (v).

Leave granted.

The recommendations read as follows-

6 (iv) Medical Boards accept the principles that the preregistration years should:

be served in more general posts with, by negotiation, opportunity for positions relevant to future vocational training; and

include a substantial component in general practice, community health centres or other suitable placements outside the hospital system,

and move to implement requirements to those effects as soon as possible.

6 (v) Funds (and training for supervisors) be made available for community health centres, general practices and other community placement agencies to provide placements for preregistration trainees in the second year experience, such funds to be provided by the Commonwealth Government (as currently happens with first year Family Medicine Program trainees).

Senator PATTERSON —I was interested to read in a June family medicine program (FMP) newsletter that the Australian Health Ministers Conference of March of this year accepted that there be two years pre-registration training, comprising a suitably structured intern year and a second year of supervised practice acceptable to the relevant medical board. The Doherty report recommends that pre-registration years should be served in more general posts and should include a substantial component of placements outside the hospital system. There has been no objective evaluation of the capacity of newly registered doctors to undertake unsupervised practice. One could imagine, despite some of the concerns expressed in the Doherty report, that many of them would compare favourably with some of the out-of-date practitioners who will be eligible under the grandfather clause for automatic inclusion on the register. How did the Government come to the conclusion that all newly registered GPs were giving inadequate care? How will the Government evaluate the effect of the increase of general practice emphasis in the undergraduate program and the pre-registration years? One could argue that it would have been better to direct some of the funding being used for postgraduate vocational training to these innovations and to evaluate these before embarking on the vocational register scheme.

There are a number of ways of assessing the levels of competence. One of these is to evaluate the examinations set by medical schools. We know that these have not been investigated by an independent body. A second way to assess competence would be at the end of the pre-registration years when an examining body could examine those medical graduates wishing to go into unsupervised general practice rather than just assuming that all post registration students are equivalent to the lowest common denominator and not equipped for the task. One can presume only that this component of the legislation was based on a deal done with the RACGP-an organisation to which only 35 per cent of general practitioners belong-a deal done to divide up the rebate increases disproportionately and to line the family medicine program's education nest at the expense of the medical schools.

The question that must be asked is: what is the matter with our medical schools if, after six years and two years now of preregistration, the ability of our commencing practitioners is being queried? Might it not be appropriate to ask what an injection of some of the funds being directed to the FMP could achieve to make good some of the deficiencies identified by the Doherty report? I am sure that the deans of our medical schools would welcome some of that funding to attract clinically qualified staff especially into the pre-clinical years, to fund the administration of the complex arrangements associated with placements in out of hospital experiences-I know that in one university some of these programs have been curtailed because there are not sufficient administrative staff, not clinical or academic staff, to organise these out of hospital experiences-and to employ part time clinicians in applied programs, tutorials and group discussions in the pre-clinical years in particular. The Minister for Community Services and Health, in a five-page propaganda letter to doctors on 30 May, said:

I think you would agree with the conclusions of the recent inquiry into medical education and medical workforce (Doherty) that current medical courses do not prepare doctors adequately to provide good quality general practice. University medical schools in the western world-including those of Australia-have as their goal the education of an undifferentiated medical practitioner who is equipped to enter intern training. In Australia that practitioner may then enter general practice or undertake vocational training in another medical discipline.

The Doherty report concluded that it is highly desirable for all general practitioners to also undertake vocational training.

The Minister is, in my opinion, suffering from an acute case of selective attention. I think Senator Sheil referred to this. The Minister is reading into the Doherty report what suits his agenda. The Doherty report recommended increased funding for final year undergraduate supervision in general practice and community health centres, increased supervised experience in these areas in the registration years and, in recommendation 8 (i), that `the Government continue its financial contribution to vocational training of general practitioners'. I ask for leave to incorporate in Hansard recommendations 8 (v) and 8 (vi) and the preamble to these.

Leave granted.

The document read as follows-

The Committee gave extensive consideration to the proposal that vocational training for general practice should be made mandatory. It saw the following points as important:

Several of the recommendations it has made elsewhere in this report (for an altered balance between hospital and community in the undergraduate course, for a two-year preregistration period including community placements and for greater support for continuing education) should, by increasing the amount of time spent in training for general practice, substantially contribute towards the quality of general practice.

The Committee is not convinced that sufficient resources and appropriate hospital and community training posts are available in all States to accommodate the needs of all potential general practitioners as well as trainees in the various specialties.

The Committee sees risks in creating what might become a disenfranchised class of registered medical graduates who are neither general practitioners nor specialists, and recognises possible cost pressures for higher fees for ``specialist'' general practitioners.

The Committee sees the mandatory concept as potentially inflexible for several groups of practitioners, including specialists reverting to general practice, graduates switching from other specialist training programs and for those returning to the work force after career interruption. It also believes that the mandatory concept would present difficulties for many graduates, for example, in hospital positions, wishing to undertake part-time general practice such as locum tenens appointments.

Accordingly the Committee recommends that:

8 (v) Mandatory vocational training and special registration of general practitioners not be introduced at the present time.

8 (vi) The Department of Community Services and Health, in five years, commission a review of the outcome of this Committee's recommendations, and of other developments, on the quality of training for general practice, and then recommend whether vocational training for general practice should be made mandatory. [8.7]

Senator PATTERSON —The Doherty recommendations which I have just had incorporated counter those being put forward in this legislation. The Doherty report recommends that `mandatory training and special registration of general practitioners not-I emphasise the word `not'-`be introduced at the present time'. Why the Government wasted its money on the Doherty report and why people pored over 400 submissions is beyond my comprehension if this is the result. The Minister has been at pains to tell us that this is not a mandatory register. Not only is the Minister suffering from acute selective attention; he is also deluded. He is deluded if he thinks that the bulk of medical practitioners, medical interns, medical students and the Opposition will swallow this bait. I guess it is okay if poorer people attending community health centres have less well trained-in the Government's definition-general practitioners who command a lower rebate, but I suppose that their voice is currently not being heard. As Senator Peter Baume said, in this debate we really have not talked about the outcome and what will happen to patients; we have talked more about doctors.

I take issue with the Minister when he says that it is false to claim that women will be disadvantaged. I wish the Minister could have been with me at the meeting in Melbourne a few weeks ago attended by more than one thousand medical students and interns. If he had bothered to consult with them he may think differently. This legislation will affect women. In particular, it will discourage young women from choosing medicine as a career-a professional course which, unlike many of the other professional courses in the universities, attracts at least 50 per cent of women. This legislation will undo that. I hope this Government will live to rue the day if this legislation goes through in its current form.

Let us now look at the non-mandatory vocational training the Minister is advocating in the legislation. Millions of dollars are being injected in the vocational training program. What do we know about the efficacy of these programs? Before the Senate supports the Government's vocational training program, it would be valuable for us to have access to objective data which is generated from the Health Insurance Commission. For example, I have seen data on a sample of FMP trainees on a GP rotation. The data seemed to indicate that while the average number of services provided in the dominant category in the survey period was 646, the minimum was 85. This is over something like a 10 week period, which means that a trainee GP sees about eight and a half patients a week, and the maximum 129. One might question the quality of the experience being gained by the trainees at either end of that extreme. Dr Hetzel, in an evaluation of the FMP program in 1986, said:

There has been no single study which indicates that vocationally trained general practitioners provide better care for their patients than untrained general practitioners.

The Doherty report referred to the review of the FMP commissioned by the Commonwealth Government in 1982 and undertaken by Hurley and Cummins. The Doherty committee reports them as saying:

There is very great difficulty in assessing standards of medical practice, including general practice, and no reliable objective measure was available to determine the effect which FMP has had on standards of general practice.

This is the very thing that Senator Peter Baume was talking about-standards of general practice; what actually happens to the patient who goes in there for the treatment and what sort of treatment that person will get. The Doherty report said-this was echoing a point made by J. S. Norell in 1981 in an English study:

the first thing which must be admitted is that their assertion, that vocational training is `a good thing', rests on a belief, as yet unsupported by good evidence, of demonstrable benefit in terms of improved patient care.

The Hurley and Cummins 1982 review said:

The FMP has probably had little, if any, influence in stimulating an increase in the proportion of medical practitioners who elect to enter general practice, and the Committee has no evidence that FMP has influenced the movement of general practitioners in areas of special need or under service or to remote areas.

The Doherty report asked the question: are there any clear benefits from vocational training? Its answer was:

Intuitively it would seem reasonable to anticipate benefits to the community from having a system for training of general practitioners. However there are no studies available that demonstrate such benefits or, conversely, the cost are incurred by not having such a system. A United Kingdom report (Norell 1981) suggested that though recipients of GP vocational training acquire certain skills earlier than non-trained GP's the differences soon disappear. Also, in surveys 10 years apart no increase was detected in certain desirable attitudes of GP's despite a substantial increase in the number of vocationally trained GP's over that period . . .

Let me assure the Senate that the Opposition is strongly in favour of continuing education and, in professional organisations, setting mechanisms in place to ensure that their members are up to date and competent practitioners. We have seen that put in place by the Australian Society of Accountants. We have seen how some of the other professional organisations within medicine such as the Royal Australian College of Obstetricians and Gynaecologists have done that very well without the sort of trauma that we seem to be experiencing in this legislation.

This part of the legislation warrants examination by a Senate select committee for a number of reasons. There is disquiet amongst many members of the medical profession and medical students. The Minister would have us believe that this is because they do not fully understand the legislation. Reference to a committee will, if the Minister is correct, serve to allay their fears. I doubt that that will happen when this committee is put in place. In fact, I think it will raise more questions than the Minister will be able to answer. There is a question mark over the efficacy and durability of the changes to general practitioners' competence as a result of vocational training. The Government's committee-the Doherty committee-has recommended that mandatory vocational training and special registration of GPs not-as I emphasised before-be introduced at the present time.

We have before us two important and divisive issues: firstly, health insurance; and, secondly, the proposed vocational register for general practitioners with the two-tier rebate system. The only reasonable course open to the Senate is to examine these issues in detail. The Senate Select Committee proposed by the Liberal and National parties will provide the opportunity for broad and comprehensive consultation. It is blatantly obvious, from the amount of concern, the number of petitions received and the amount of lobbying that has gone on, that the medical profession as a whole, is not, as the Minister indicates, fully informed. I think that, as a result of reading that letter he sent them, they will be even less informed. The community is not informed. It has not been broadly consulted. This Committee will enable that comprehensive consultation. After that, and only after that, will we have the much more considered and informed decision that that Labor Government opposite has denied the people critically affected by this Bill.