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Tuesday, 13 June 1989
Page: 3909


Senator PUPLICK(9.40) —I wish to address some remarks to clause 10, which deals with the establishment of the vocational register and the differential rebates for general practitioners. I ask the Minister to answer specifically a question that Senator Peter Baume raised in his address during the second reading stage. I ask him squarely: How does a system of differential rebates paid to general practitioners assist patients? Also, can the Minister tell me when the Government will respond to the recommendations of the Doherty report? The Doherty report has been raised at some length in debates this evening, and in particular in a very perceptive address in the second reading debate by Senator Patterson. The Doherty report, which was entitled Australian Medical Education and Workforce into the 21st Century, dealt with the question of continuing medical education. I read the following extracts in relation to this matter from pages xix and xx of the report of the Committee of Inquiry into Medical Education and Medical Workforce:

The Committee gave extensive consideration to the proposal that vocational training for general practice should be made mandatory.

It goes on to discuss certain matters and states:

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 program 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.

I appreciate that the Doherty report is talking about mandatory vocational training and the Government is talking, it says, essentially about voluntary vocational training. There is certainly a difference. But quite clearly, the issue of the extent to which the financial pressures become almost mandatory for those seeking career advancement is one which the Government has not addressed. So we have two questions, and I will come back to them in a moment: firstly, how do differential rebates to general practitioners assist patients; and secondly, when will the Government respond to the recommendations of the Doherty report?

I turn to the analysis which I believe correctly identifies the fundamental weakness in this vocational register. I will quote at some length the comments made in the House of Representatives on 25 May 1989 by my colleague Dr Michael Wooldridge, the member for Chisholm. Dr Wooldridge stated:

The worst thing about this proposal is the closed shop nature of it. Prior to my entering Parliament I was involved in discussions as a representative of the younger doctors with members of the College, with the Family Medicine Program (FMP) and the Australian Medical Association (AMA), and I can tell the Minister that after all those discussions representatives would tell me that what this was really about was the hope that one day they could control medical manpower in general practice. What they want to do is put up a hurdle that is so great that it will stop people entering general practice.

The Minister has talked about what happens overseas. He has told the House that in Canada this happens and in England this happens. I would like to tell him what the Doherty report said. This was a report the Minister commissioned. I am sure he knows it. In the United Kingdom: four years training including registration. This is compulsory. I am referring to page 267 of the report. In New Zealand: voluntary, one year. In the United States: voluntary, three years. In Canada: voluntary, two years. What are we doing in Australia? Involuntary, six to seven years; and that is what it is, because we have one year internship with proposals around the States to make it two, and to become a Fellow of the Royal Australian College of General Practitioners it is now five years. These conditions are not applied anywhere else in the world. This scheme will reduce the number of women that can do that sort of training, just like the College of Surgeons has done, and the Government will consign to the scrapheap some of the most idealistic and capable young people that this country has.

I put it to you, Madam Temporary Chairman, that no country has proposed this length of service. Allegations about the Swedish system have yet to be substantiated by anything that the Government can bring forward in terms of the training which is required for qualification for entry into the scheme after it starts in its new form and after those who are already practising have been grandfathered-which is the stated term-into this scheme. As Dr Bryce Phillips, the Federal President of the Australian Medical Association, has said, in many respects the scheme is a blank cheque for more government control of the medical profession. It has been introduced with virtually no consultation within the wider medical profession. The Government has negotiated solely with a small select group of negotiators within the Royal Australian College of General Practitioners which represents only a small proportion of those upon whom the changes will impact. We made the point earlier today that a large number of general practitioners do not support what the College has allegedly done on their behalf.

This scheme will split general practitioners into two distinct groups: those who are registered-and therefore their patients will receive a higher rebate-and those who are not. I want to indicate the discriminatory nature of that operation. I quote from a paper circulated to honourable senators which was prepared by a number of recent younger graduates-Dr Zelle Hodge from Brisbane; Dr Rod Macrae from Melbourne; Dr Amanda McBride from Sydney; and Dr Ann Geschke from Melbourne. They say in their paper-I propose to read a fair bit of it-that the legislation strikes hardest at some of the groups in society most susceptible to the effects of financial hardship, including women, children, country people, university students and the terminally ill. The paper states:

Women patients are demanding women doctors. This is supported by the Federal Government's own National Women's Health Policy released in March 1989 at the Australian Health Ministers Conference. However, this legislation will discriminate against women practising medicine as General Practitioners, both in the training requirements which go far beyond the accepted overseas training requirements, and basic hours worked per week before eligibility, for the Vocational Register.

This means that the patients (that is women and children) of these women doctors will be financially disadvantaged.

Senator Crowley indicates her support for that further disadvantage against women and children in Australia. The paper continues:

Furthermore, discrimination will exist against those doctors that practise in areas of: women's health, breast and cervical cancer screening, and family planning clinics.

Clearly, this is also discrimination against women patients requiring these health and medical services.

Women patients are demanding women doctors yet the length of training precludes many women from a long-term career commitment in medicine after six years undergraduate and five years post-graduate training. Discriminated Patient Groups in the wider community include:

Country Patients . . . accessibility to registered doctors

Lower socio-economic groups may not have access to doctors on the Vocational Register

Ethnic patients e.g. a Vietnamese community, may not have access to doctors on the Vocational Register.


Senator Crowley —You are marvellous!


Senator PUPLICK —Senator Crowley is not in the least bit concerned about that, and I can see her nodding from here. The article goes on:

Patients of special interest doctors are discriminated against if the doctors themselves are discriminated against.

It gives the example that, where a doctor practises and has two sessions per week as a general practitioner, he or she may be accredited by the college, but if three sessions, for example in women's health, are added, these are classified as not being predominantly in general practice and are, therefore, not accredited.


Senator Crowley —That is not the latest advice that I have.


Senator PUPLICK —Senator Crowley is mouthing her support for that system of discrimination once again. The doctors, in their paper, go on to discuss overseas training, which I have already alluded to by reference to the speech made by Dr Wooldridge in the House of Representatives; the question of confidentiality-and I propose to come back in a moment to the Independent Peer Review Organisation-and questions of cost-efficiency. They conclude by putting what they describe as a young doctor's viewpoint in these terms:

Resident Medical Officers and undergraduates have no confidence in the RACGP following the way this legislation has been handled and have lost faith in the Government following their failure to consult graduates and students.

Extreme concern exists as for the value of the MBBS. This legislation makes it virtually worthless.

Extreme concerns exist as to the funding and assurance of training positions, with questions of exploitation in the process, particularly through the Family Medicine Program (FMP).

There is a fear that Resident Medical Officers will abandon public hospitals to meet GP criteria, further stressing an overburdened system resulting in the deterioration of health care to the Australian public.

The 2-tier rebate concept: undermines the fundamental industrial principle of equal work for equal pay.


Senator Crowley —I don't know how you don't blush.


Senator PUPLICK —Presumably Senator Crowley is quite happy to undermine that principle. She comes in here and beats her gums together on a number of occasions about equal work for equal pay; nevertheless, she is quite happy to have this differential rebate so that some people are being positively discriminated against by this Government legislation-


Senator Crowley —You pay the specialists more; you pay the specialist obstetricians more. You should blush, you know.


Senator PUPLICK —If Senator Crowley were paid on the basis of her net worth she would be a pauper. Patients and doctors will be disadvantaged under this legislation by government fiat on the basis of whether they are on a vocational register, as designed by a cosy agreement between the College and the Government on this matter. The Opposition believes that these are the sorts of issues which should be examined in some depth in the Senate Committee inquiry, and the evidence will speak for itself.

Earlier today Senator Crowley made a very interesting remark about Senate committees. She said this reference was being `dumped on Senate committees'. They were her words. She said she understood that the role of a Senate committee was to take its riding instructions from the Government. That is typical of the way in which elements of the Labor Party think Senate committees ought to work. They think they are there simply as flunkies for the Government of the day. According to Senator Crowley, given that Senate committees have a majority of Government members, they should have their terms of reference given to them only by the Government. We know the way in which Caucus operates. We know that Senator Crowley would no more criticise her factional colleague Dr Blewett than she would make a serious contribution to a public health debate. She has expressed the attitude that the proposed Senate inquiry should not be established because the Government has not given it its terms of reference. That is precisely what the Opposition believes the Senate Committee ought to do: it ought to look at all things including those which are a potential embarrassment to the Government, to see where the facts lead. The facts will speak for themselves if the Senate Committee is given the opportunity, as it will be, of dealing with this very complicated but very important part of the legislation.

I therefore conclude this part of my discussion of clause 10 by asking the Minister again: How will the differential rebates paid to general practitioners assist patients? When can we expect a response to the recommendations in the Doherty report?