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Tuesday, 13 June 1989
Page: 3883

Senator KNOWLES(5.27) —Tonight we are debating a number of Bills cognately-the Community Services and Health Legislation Amendment Bill 1989, the Supported Accommodation Assistance Bill 1989 and the Aged and Disabled Persons Homes Amendment Bill 1988. As my colleague Senator Patterson previously said, it is a shame that through the Government's mismanagement important Bills are always debated cognately and rammed through together at the end of a session. This really does not give us the opportunity to address the very important aspects of the legislation before us. Tonight I wish to address my comments to two main features of the Community Services and Health Legislation Amendment Bill. The main feature of this Bill constitutes a real confidence trick of a Labor Government that is telling us that it is doing a favour to doctors and private health care in a rather vain attempt to take health off the agenda prior to the next election and to tickle the tummies, I suppose, of some of the doctors who have been almost bashed to death by this Government over the last six and a half years.

This Bill is very interesting for a number of reasons. I suppose it is distinguished by what information it does not contain. We are being asked to make decisions in the Senate today without being privy to specifics of what the Bill is all about. The Government's rhetoric may have changed but the substance is not far different when it comes to the two principal aspects of the Bill. As I said, after all the doctor bashing that Dr non-medical Blewett has conducted over many years, the Government seeks to create a discriminatory vocational register of general practitioners (GPs) under the ultimate authority of the Health Insurance Commission, under the guise of raising the status and incomes of some doctors, while it has spent so many years reducing the real incomes of doctors. It also seeks to redistribute the burden of reinsurance within the private health sector without regard to the long term viability and survival of private health insurance.

The Minister for Community Services and Health (Dr Blewett) talks of the new general practitioner fees package rather than the method of its implementation-a two-tier system of general practitioners that will inevitably brand many as somehow second-class doctors. We have heard from the Government today and on previous occasions that this legislation is not going to create second-class doctors, but in fact we see in the Bill itself the very words that will allow it to create second-class doctors. I wish to quote from proposed new section 3f (9), which states:

The General Manager of the Commission or an authorised officer may make available to members of the public, on request, the names of medical practitioners who are registered under this section and the addresses at which they practise.

That really rings alarm bells to me for a number of reasons. First, it creates those who have been registered and those who have not. Secondly, it has the probable ultimate goal and effect of creating a preferred provider scheme, and that is something which I think many doctors, particularly those being pushed by the Royal Australian College of General Practitioners (RACGP), would find abhorrent.

When the Minister speaks of an agreement reached between the Government and the Royal Australian College of General Practitioners, he underscores the fact that other important facets of the medical profession have not been consulted. Those facets are more strongly opposed to change that is ill-considered, whatever the sincere beliefs of the RACGP, which, I might add, represents less than half of Australia's general practitioners. The Minister admits that there has been little consultation, yet the Government is trying to ram this Bill through the Senate in the dying hours of this session to try to bluff us, the doctors and the community in general.

The Opposition is saying that this matter should go to a select committee, as opposed to what Senator Crowley said about its going to the Senate Standing Committee on Community Affairs. It is not going to that Committee, and if Senator Crowley attended some of that Committee's meetings she might know a little more about what happens there. Before she comes in to take any point of order or to make a personal explanation, I suggest that honourable senators check both the minutes of that Committee and the Hansard transcripts to see how regularly she does not attend. We are suggesting that this matter should go to a Senate select committee for further consideration and further and proper consultation with those who are concerned with the outcome, and that should be all of us, because ultimately it comes back to us and the effect it will have on us as a community generally.

It is rather characteristic of this Labor Government to use part of the medical profession to sell these changes, just as it tried to hide behind the Voluntary Health Insurance Association of Australia to push the case for its bandaid solution on the bucket reinsurance changes. Indeed, the Health Insurance Commission is funding the promotion of the new arrangements by the RACGP, and this has been revealed in the following editorial from the Medical Observer, which I wish to quote from because it concerns me. I think it would also concern many of the general practitioners who have taken the lead from the College to write to many senators and members calling for `the early passage of this legislation'. The editorial says:

`The Royal Australian College of General Practitioners . . . has accepted responsibility of promoting the accord to all Australian general practitioners prior to the introduction of the differential fee rebates on 1 August 1989.

`This promotion will be funded by the Health Insurance Commission which will give broad guidelines on the avenues of promotion and the target audiences.

`These include the public and a significant proportion of the funds will be used as media advertising just prior to implementation date, these funds having the secondary gain as good vote-catching material.'

I think many doctors would now be concerned that they had been used as pawns by this Government to get the issue of health off the agenda. The standard of health care in this country has steadily declined ever since the Whitlam years and it has further declined since the Hawke Labor Government came to office in 1983. Let there be no question at all that the medical profession as a whole has not been taken in by this Labor con trick. On 31 May, a meeting at the Charles Gairdner Hospital in Perth, attended by 80 health professionals-doctors and medical students-overwhelming rejected the case for a vocational register as put by the RACGP. Significantly, 50 per cent of those attending the meeting were female. Despite the Labor Government's denials, it is proposing to erect an enormous barrier to the 45 per cent of medical graduates who are women and who may wish to enter general practice.

The Opposition believes that the requirement to complete the certificate of training approved by the RACGP in order to qualify for the vocational register is discriminatory in respect of a number of important medical fields. My belief that it is discriminatory is based on a document which supposedly contains the sweetheart deal that has been done between the Government and the College, but which is not contained in this Bill, so we do not know the detail. All we can do is assume that the deal has been done. The Bill does not spell out or even hint at the requirements that we are being asked to vote on here this evening. Doctors who have worked in such fields as sports medicine, clinics for students, women's health or family planning and who have not fitted in five years of general practice, will be denied entrance to the register based on that deal that has supposedly been done with the Government.

The requirement of what in effect is 11 years full-time training before qualification for the vocational register will prove prohibitive for women graduates who, having completed their degrees and internships, then wish in their late 20s or early 30s to have children and practise only part-time. Supposed concessions enabling current women GPs, who have worked part-time in their child-bearing years, to qualify for the register under the five-year grandfather clause, ignore what will happen to today's students and young resident medical officers and the situation that will prevail after 1995. I was alarmed when Senator Crowley said earlier this afternoon that women doctors had not a thing to worry about. I think it is rather sad that a Labor senator can promote this legislation and quite deliberately mislead doctors by saying that it will not affect them. It will, and we can categorically--

Senator Tate —Mr Acting Deputy President, I raise a point of order. Senator Crowley has been accused of deliberately misleading doctors. I do not believe that is parliamentary. I believe that she may have misled them inadvertently, though I do not think that is proved. But to say that she has deliberately misled them is to cast a reflection on the character of Senator Crowley.

The ACTING DEPUTY PRESIDENT (Senator Crichton-Browne) —My understanding was that the expression used was `inadvertently misleading'.

Senator Knowles —No, it was not.

Senator Tate —No, I am sorry, it was not. It was `deliberately misleading'. I think Senator Knowles will acknowledge that.

The ACTING DEPUTY PRESIDENT —Order! I am certain that if Senator Knowles said `deliberately', she will be happy to withdraw.

Senator KNOWLES —I will withdraw the word `deliberately'. But I believe that Senator Crowley has, by her words this afternoon, misled many doctors who, having heard her, would now believe that they are not going to be affected. This Labor Government will in effect be telling a generation of young women that, if they want to be mothers as well as doctors, they had better resign themselves to being permanently in the second tier group of general practitioners. The losers will be not only the graduates but also those patients who might quite validly prefer to see women general practitioners. How ironic it is that the Hawke Labor Government, which brought in laws to regulate private conduct in the 1984 Sex Discrimination Act, and which sought to regulate business through affirmative action legislation in 1986, is now condoning discrimination against women medical practitioners.

As a Liberal I believe in equality of opportunity for men and women alike. I shall always oppose reverse discrimination, but we have here an undeniable disadvantaging of highly motivated and qualified women because they have exercised the human choice of motherhood or the professional choice of working in specialised health areas of concern to women. The Senate needs to be aware that the concession of allowing two half days per week in general practice over five years for current medical practitioners to qualify for the vocational register applies only to strictly routine work in approved practices. Should the doctor in question have been working other half days during the same period in some other form of medical work, such as specialised clinics, he or she will not qualify. To have worked four sessions per week over four years in general practice is less acceptable than the vaunted two sessions in five years, which to me is a further example of the bureaucratic and restrictive nature of the proposed requirements. It would be of great interest to know just how many women general practitioners were consulted by the non-medical Dr Blewett and his Department before they made the use of the agenda of the RACGP that suited their purposes.

It is only a few weeks since 20 April when the Prime Minister (Mr Hawke), amidst the customary fanfare, launched the national health policy, full of such high-sounding but insubstantial promises of better services, information, data collection, training and participation in decision making. Even he had the gall to say that women `want more women to be trained to deliver those services'. Yet his Government is the government that here today is trying to disenfranchise women. The limitations that the Bill will impose on opportunities for women to serve as general practitioners make an utter farce of this policy.

As a Liberal I do not support the concept of what the Government is doing. However, I do support a general concept of encouraging the highest degree of capability of Australian general practitioners and of ensuring that their professionalism is fairly remunerated. What we have seen year after year, as I have said before, is this Government trying to pull down the real incomes of doctors. Now, through some miraculous foresight when it sees an election around the corner and identifies that health will be a major problem, it says, `Whacko, here we go. We'll increase doctors' fees, but we'll make two classes of doctors in the process'. That is just not desirable.

I question the assumption that the Government's objectives are best achieved through compulsory vocational training. Non-medical Dr Blewett is not accurate in stating that the vocational register is consistent with advances occurring in many similar Western nations. The facts do not support that. The facts are that in the United States, Canada and New Zealand vocational training for general practitioners is voluntary and extends respectively for three years, two years and one year. In Britain a mandatory vocational training scheme of three years has been in effect since 1982, but the April 1988 report of the Committee of Inquiry into Medical Education and Medical Workforce noted that studies into the characteristics of United Kingdom general practitioners have not shown any change since then.

This raises the basic question as to whether mandatory training produces better patient outcomes. Clearly, the Labor Government in drafting the Bill has ignored the recommendation of the inquiry that received evidence from bodies such as the Hospital Doctors Association of Western Australia and the Australian Medical Students Association, stating that the program proposed by the RACGP was too long. The inquiry recommended against compulsory vocational training for general practice on the grounds that insufficient suitable training posts were available, a disenfranchised class of registered medical graduates would be created, and the concept would prove a barrier to various categories of practitioner-just as this legislation will prove to be. Is it not a shame that here we have yet another example of a government refusing to take on board the results and findings of an inquiry? We have seen that happen time and time again. Probably the most notable inquiry that the Government refused to look at was the inquiry into the Australia Card. It decided to go ahead with its proposal. In this case the Hawke Labor Government has, at best, bought into one side of a very complex professional argument without proper consultation.

I would also question the assumption that those doctors who do attain a place on the vocational register will not benefit financially to anything like the extent the Government suggests. There is no question that doctors outside the register will be forced increasingly to rely on other methods to survive. Given the Labor Government's track record in its treatment of health professionals, who are front-line targets whenever scapegoats must be found for the inherent costs of Medicare, it will have a deep vested interest in keeping the vocational register as small as possible to limit the amount of higher rebates.

Senator Crowley also said this afternoon that the only complaint I could make about Medicare concerned waiting lists. She must have been on some other planet for the last 4 1/2 years. If she had bothered to listen, she would have heard me give her a list as long as one's arm of what is wrong with Medicare. The list gets worse and worse, to say nothing of the list of people waiting for treatment in public hospitals, which she could not deny is very severe. Again, there is a fundamental flaw in a Bill that gives ultimate control of a vocational register to the Health Insurance Commission and leaves such sensitive and essential questions as auditing to future finetuning legislation in another session of Parliament. That is just an utter disgrace. The Government says, `Vote on something tonight and we will finetune it another day'. Why on earth should any of us do that?

What is of even more concern is that there is no appeal process in this whole structure. The Health Insurance Commission, through the RACGP recommendations, can put people on or off the list. However, if they are taken off the list there is nothing to allow an appeal. How much more unfair could that be? The Bill talks about minimum requirements. What are the minimum requirements? We should not ask because the Government will not tell us anyway. The situation is a particularly serious one, as is the situation with reinsurance. Just as this Government seeks to con general practitioners into thinking that it is doing them a favour, so too does it pose as the saviour of the major private funds of the health insurance industry. The Minister actually stated:

I have always maintained that Medicare's continued success and high popularity is dependent upon the maintenance of a strong, viable private health care sector.

That in itself is an admission of the failure of the whole concept of socialised medicine. Similarly, for decades Soviet agriculture was saved from collapse by the relatively small amounts of land farmed independently by the peasants. The Minister's hypocritical admission is not matched by effective action. The industry is getting a Private Health Insurance Administration Council so that the Department can do its dirty work at arm's length.

All insurance costs for those contributors over 65 will be met from the reinsurance pool, forcing up the premiums of the employment based closed funds and newer funds to meet increased contributions to the pool. The Government is doing no more than imposing a mechanism to meet the immediate losses of those major funds with high proportions of elderly contributors, and its own contribution to the reinsurance pool is a one-off $20m-an amount equivalent to less than 0.2 per cent of the 1988-89 health budget allocation. The Government tells us how wonderful it is in putting $20m back into the reinsurance pool, but it does not tell us at the same time what it has taken out since it has been in office. Clearly, this is no more than a bandaid on the bucket that is supposedly upholding the community rating principle to which the coalition is strongly committed. In fact, it will have the effect of weakening the same principle. If younger and fitter members of the new for-profit funds, when confronted by increased premiums, should choose to let their insurance lapse and rely upon what the Government, with its other face, still promotes as a free Medicare system-free, my boot-then the needs of elderly contributors will be met from a shrinking financial base and the basic problem will be exacerbated. For community rating to work effectively and justly, there must be real incentive for Australians in good health and below the retiring age to maintain private insurance. No insurance system can survive without coverage of low risk groups.

Under this Government there is no incentive to maintain private health insurance other than if someone wants to have surgery when one requires it. There is absolutely no financial incentive whatsoever. The supposed incentive offered by the Government is for people to pay twice-pay their Medicare levy, which covers about only one-third of all Medicare and health costs, and pay their private health insurance premiums. It is not the fault of the smaller health funds but that of the whole Medicare system that the Hospital Benefits Association Ltd in Victoria suffered a decline in membership from half a million to 253,000, losing another 13,000 members last year. How typical, I might add, that these figures are public because the Federal Department leaked them. So much for the new-found friends of private insurance!

Private insurance, which used to be enjoyed by 63 per cent of the population in 1983, looks to a decline from the present level of 46 per cent coverage not only because of the inherent structural problems of Medicare but also because of the deliberate policy adopted towards the private health sector by the Hawke Labor Government. This Government has withdrawn $99m from its contributions to the reinsurance pool, removed the $140m bed subsidy for private hospitals, forced the private funds to pay a 25 per cent gap in the public hospital costs of privately insured patients and stipulated that all such patients shall be regarded as private patients, whatever the nature of their treatment and accommodation within a public hospital. It is no wonder that the Australian Private Hospitals Association realises that this stopgap solution will be of no benefit to private hospitals when public hospitals have every incentive under Medicare to attract private patients, leaving private hospitals with spiralling costs that many privately insured Australians can no longer afford. How sad it is to hear Labor senators talking about reducing the queues in public hospitals by creating more public hospital beds, while there are private hospital beds not being utilised. Their socialist stance will not allow them to see the benefits of private health insurance, private health cover, private doctors and private hospitals.

For all its lip service to the private health sector that saves Medicare $2.7 billion annually in hospital costs, this Government, by its actions, shows that it is prepared to further a situation where the percentage of privately insured Australians will fall. With each one per cent fall in private cover, the annual cost to public hospitals increases by $80m. On the other hand, a realistic contribution to the reinsurance pool of $200m-not $20m-would enable a 10 per cent reduction in private health contribution rates to be made. That, in turn, could result in a 10 per cent increase in those covered and this would save the public health sector $200m annually. Otherwise, this legislation, conferring a minimal benefit on 70 per cent of those privately insured and a massive disincentive on the remaining 30 per cent to maintain their cover, is taking us towards a situation where, in five years time, we will be lucky to have 40 per cent of Australians retaining private cover.

Private health cover should not be something that is exclusive to the wealthy. This Government is making it more and more that way, because private health cover is now becoming a luxury. People faced with high interest rates are now deciding, more and more, to opt out of private health cover, thus putting more and more of a drain on the public purse. We should remember that governments do not have any money; they have only taxpayers' money. It is not sufficient for people to run around saying, `The Government should provide'. If there were an incentive for people to provide for themselves, there would be less demand on government. But this Government is so blinkered that it will not consider that alternative.

This legislation will mean an increase in the massive queues at public hospitals while private hospitals close, and those that do survive will be priced beyond the range of ordinary Australians. This deceptive Bill, when examined, shows that the Hawke Labor Government is no friend at all of the medical profession or the private health sector. We urgently need the select committee of inquiry that will look at the real issues concerning health that the Government, quite deliberately and consistently, seeks to evade. Foremost among these issues must be the ability of hospital Medicare to meet its basic objectives. We need to establish what support needs to be provided to the private health sector if community rating is to remain a reality. The only option we have is for the whole subject to be looked at in great detail by a Senate select committee which, at the end of the day, once the subject has been sensibly and thoroughly assessed, can make a balanced decision-not a decision based on a piece of legislation which contains no information and no facts about what we should be voting for. That should be a source of major concern. I hope that general practitioners and health insurance funds understand the ability they will have to communicate their concerns to the select committee.