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Select Committee on Red Tape
Effect of red tape on health services

BONANNO, Dr Carmelo, Vice President, Australian Dental Association

NGUYEN, Mr Bryan, Senior Policy Officer, Australian Dental Association

PINSKIER, Dr Nathan, Chair, RACGP Expert Committee, eHealth and Practice Systems, Royal Australian College of General Practitioners


Evidence from Mr Nguyen was taken via teleconference

CHAIR: I now welcome representatives from the Royal Australian College of General Practitioners and the Australian Dental Association. Thank you for appearing before the committee today. I invite you to each make a brief opening statement if you wish to do so.

Dr Pinskier : I'm here today on behalf of the Royal Australian College of General Practitioners. The RACGP is Australia's largest professional general practice organisation and represents over 38,000 members working in or towards a career in general practice. I'd like to begin by thanking the Red Tape Committee for inquiring into how to reduce red tape in health services. General practice, like all other health services, has a core focus and objective of keeping the community healthy. Time spent dealing with unnecessary red tape is time that could've been spent providing direct service delivery and caring for patients. General practices are predominantly small businesses, with either small administrative teams or, on occasions, no administrative support at all. GPs are often the people responsible for undertaking these time-consuming administrative tasks. This significantly impacts on the time that GPs can spend providing direct clinical care to their patients. Based on our member data, the RACGP estimates that GPs spend approximately 20 per cent of their time on management, administrative tasks, completing paper forms or other indirect patient care. Based on a five-day working week, this equates to an entire working day that could have been spent providing direct patient care.

Our submission to the inquiry reflects feedback we have received from grassroots GPs. It outlines some, but not all, of the red tape issues faced by GPs. It also highlights a key cause of red tape in general practice, the lack of interoperable government automated and integrated systems to manage key information capture and data transfer. This is equally true at both the Commonwealth and state or jurisdictional level. Many of the administrative tasks that GPs are required to undertake to support direct-care delivery and to allow patients to access additional care or services can be improved and modernised through the better use of technology, which should be a core consideration of the government's digital transformation requirements. General practice is predominantly electronic at both an administrative and a clinical level, yet it interacts with a healthcare world that still relies heavily on paper and faxes. To state the obvious, this is out of step with the massive changes that have occurred in other sectors of the economy.

The healthcare sector represents 10 per cent of GDP in Australia. This means that one in 10 dollars spent on digital transformation should be allocated to this sector. This is unlikely to be a truism. Whilst it's important that existing red-tape issues are addressed, it's equally important that processes are established to ensure that all future regulatory or administrative requirements do not create new or additional unnecessary burdens on GPs. This requires a priority review to ensure harmonisation of processes at a COAG level: one country; one integrated healthcare system.

Additionally, it's essential that GPs are adequately consulted, engaged and heard during the development of new requirements, administrative processes or proposed system redesigns. GPs understand the healthcare system, its limitations and the opportunities for change and improvement. We undertake over 130 million consultations per annum. On average, that's six visits per person per year. We liaise with a large number of other healthcare providers—with hospitals, with care support agencies—and with numerous government departments. We deal with healthcare issues in a timely and responsive manner. We see and feel the pain point. We want to help make the system better. That's part of our ethos: to make things better and to see less red.

Thank you again for inquiring into how red tape in the healthcare service can be addressed. I look forward to answering your questions.

CHAIR: Thank you. Dr Bonanno?

Dr Bonanno : Good morning. I'm the Vice-President of the Australian Dental Association. The Australian Dental Association thank the select committee for the opportunity to elaborate on our submission about the impact of red tape, particularly on dental services in Australia. The ADA is the peak national professional body representing more than 15,000 registered dentists as well as dental students. Around 85 per cent of dentists work in private practice. That represents approximately 7,500 small businesses employing an average of six people in each practice. This is where the burden of red tape is especially felt.

Red tape can make or break a small business. Red tape increases costs for consumers. As we've outlined in our submission, there is a significant amount of red tape that exists in the dental sector. What this means is that dentists are spending more time and resources in ensuring compliance than they are in treating patients. When resources are spent in compliance, that cost has to be subsumed somewhere; otherwise there won't be a business. So it's understandable that some of the costs will be passed on to patients. This has most impact on the very people we should be looking after in the community—the disadvantaged.

The ADA has been concerned about the increasing burden of red tape in dentistry for a very long time. In 2006, we commissioned Deloitte Access Economics to look at this very issue. At the time of the report, Deloitte estimated that gross regulation related costs for dental practices averaged the equivalent of $84,400, in 2006 dollars, across Australia—or $397 million across all private dental practices. We expect that amount to be much higher now, as that analysis was of the regulatory landscape in 2005-06. The advent of the national law regulating health practitioners, and the manner in which it has been implemented, along with other red tape outlined in our submission, has very likely increased the burden on small dental practices and dentists.

There are a number of examples of red tape that the ADA believes must be addressed. Many of the submissions the committee has received echo the sentiments of the ADA. That is why the ADA urges the committee to recommend steps to address the duplication that exists in relation to infection control regulations and onerous health practitioner registration renewal requirements; that a national and uniform approach is adopted when it comes to licensing for the ownership and use of radiation machines; and that Australia moves towards national uniform drugs, poisons and medicines legislation, including appropriately setting thresholds for regulation of teeth-whitening products that bar unqualified and unregistered people from putting the public at risk.

On behalf of the ADA, I'd like to thank the committee for having us present today. I welcome the opportunity to answer any questions.

CHAIR: Thank you. Senator Paterson, do you want to kick off?

Senator PATERSON: Dr Pinskier, I'm interested in your comment about the amount of GPs' time that is taken up with admin and management tasks. I'm not sure how that would compare to other industries, but it sounds pretty high to me—20 per cent is pretty high. I think there's a general view that technology is part of the answer in fixing that. Do you share that view?

Dr Pinskier : Absolutely. I've been chairing the college's expert committee for five years now. In a previous life I was the deputy head of the clinical unit at the National E-Health Transition Authority, and I currently engage with the Australian Digital Health Agency, its successor. I chair the secure messaging taskforce and the pathology uploads to My Health Record technical working group. I have extensive knowledge of how eHealth works, what the opportunities are and what the current barriers and limitations are. I also sit on the board of the public hospital network in Melbourne Peninsula Health. I see how it operates with all the challenges within the hospital sector. I have engaged with the federal Minister for Health directly on these issues. I'm sure the government is across some of these issues. We can make substantial improvements if we create harmonised approaches to the way we implement eHealth as opposed to the current ad hoc system, where government departments still request, on many occasions, faxes to be sent, and where hospitals still require us to send faxes for urgent conditions. We create electronic documents in our electronic systems, but then we have to print them out and fax them, and then they get scanned at the other end. It's an archaic system.

Senator PATERSON: That seems pretty crazy. I do have a fax in my office, but I think in my two years in the Senate I've received about two real faxes.

Dr Pinskier : I turned mine off. I turned mine off five years ago. I say to people, 'If you have to fax me, I don't want to do business with you.'

Senator PATERSON: That's probably pretty fair. So government departments and hospitals sometimes actually require you to fax information?

Dr Pinskier : Consistently. Because they haven't got the systems by which we can create an electronic message send it securely, although the technology exists.

Senator PATERSON: They don't have email?

Dr Pinskier : They don't have secure email. The challenge is to comply with the Australian privacy principles. Sending over open email is akin to exposing data. Then you run into the problems of data breaches. From 22 February we have the mandatory breach reporting. So that creates all sorts of unintended consequences. If it's out there, it's out there. Using a secure system means that it can be sent from one end point to another without being intercepted in the middle if it's encrypted. The problem is we have so many different secure messaging products out there, and the government hasn't actually chosen a standard for its own sector, federally or at a state level.

Senator PATERSON: I'm not sure that's a problem; that just means there are lots of things to choose from or lots of options available.

Dr Pinskier : From a red tape perspective, it means in my practice currently I have five or six different secure messaging products. It's like having a different fax machine for every person you deal with. What we want to create is interconnectivity. The college put out a statement two years ago saying that within three years we would like to see the whole of the healthcare sector being able to send secure messages—secure and interconnected. It doesn't matter whether you have a Telstra phone, an Optus phone or Virgin phone; if you send it, it should be received by the receipt. We have worked with the Australian Digital Health Agency—the government supported this—to actually implement trials. Those trials are happening this year. I would like to say that by the end of this year we would have some interconnectivity. That will be within our sector. Actually getting government agencies to then adopt those standards is a much more complicated problem.

CHAIR: Cabinet has done it; they're all on WhatsApp.

Senator PATERSON: That's right, they are. Dr Pinskier, how much is the rollout of the eHealth personal records going to assist in this process? How much difference will that make?

Dr Pinskier : One of the good things that My Health Record, which was once called the Personally Controlled Electronic Health Record, has done is to create a set of standards around data transfer, known as CDA standards. The general practice software has those standards and it can send data to My Health Record, which means another provider who has not previously seen that patient can download that information. The My Health Record is not in itself a communications tool; it's a repository of information that can be accessed as and when appropriate. What we need to do is to build on those standards to ensure that they are embedded into what we call provider-to-provider communication or point-to-point communication. So if a patient goes to hospital, when the patient's discharged, rather than a letter or a fax, I would get an electronic message directly into my inbox. That would significantly reduce red tape and improve healthcare delivery.

Senator PATERSON: I guess it is a communications tool, say, when someone moves house and they go from one GP to another, so their personal health data is accessible to that new GP.

Dr Pinskier : It's a repository for the consumer to be able to manage and access their own healthcare information. It is a repository for other providers who don't already have that information. It's the itinerant patient seeing the itinerant provider. We have done an enormous amount of education to our sector and hopefully this year we will do additional education to the sector to explain how My Health Record can be enhanced, particularly as it moves to opt out from the middle of this year.

Senator PATERSON: Dr Bonanno, do dentists use faxes?

Dr Bonanno : Yes, I have a fax machine. I think mine's been used twice more than yours has in the last few years. You've raised some very good points here, Dr Pinskier. I will just expand on those a bit. We're aware of the national privacy principles as they relate to communication and patient records. It is something we educate our members about. But we have the same level of frustration. Unless you've got a messaging product—and, again, without the standards for secure messaging products it's very, very hard to move forward on this—apparently, the only secure way of communicating patient records is through snail mail. Apparently, that's more secure than electronic mail.

Senator PATERSON: I have my doubts.

Dr Bonanno : But that's the thing. We've made representations about that, but they go nowhere. The other thing, too, is that—and I think this is probably more so for the doctors—you see patients on an emergency basis, so what you need to do is ensure that there is quick facilitation and transfer of information so that, if someone needs to be seen urgently, the information's there. We're talking about X-rays, clinical notes, medical history et cetera, and if you communicate with a colleague through email, you're actually breaking the law. So, then, the patient can't be treated effectively, or they can't be treated expeditiously, because of what I think is some legislation that's been created which doesn't really look at the practical issues behind the whole secure messaging issue. That's just one area. I think we're on the same page with that.

CHAIR: I find it interesting that ordinary snail mail should be regarded as secure while email is not. Do you have any thoughts on that?

Dr Pinskier : I think it's essentially by convention. It's a thing that people find easy to do, and, in the absence of having a clinical information system and having gone through the process of the transformation, people gravitate to the easiest or the most recognised option, which is snail mail or faxing. General practice has gone through a transformation now over about 20 years where probably 99 per cent of general practices are fully electronic at both a clinical and an administrative level. If we look at the rest of the healthcare sector, it's far lower. If you're a specialist who works alone and has no administrative support in an office, it's much easier to dictate a letter up to a central repository and then have them send a letter or a fax as opposed to investing in technology that will support secure messaging. They all work. The problem is that, once I get that piece of paper into my practice, I've got to scan that. It becomes an image I can't search. The data is not what we call atomic data; it's not easily discoverable. I lose the content and I lose the ability over time to track that information, so, if I want to track your blood pressure over the last three years, if it comes in a fax, I can't do that. But if it comes in an atomic blob, I can have that in my system in a codified form, using the Australian national standard, SNOMED CT-AU, and then I can start to do some really interesting work and research, and that leads to quality improvement over time. It gives better health care to you; it gives better population health data to the community.

CHAIR: You also mentioned in your submission the failure to accept electronic signatures. Can you just explain that?

Dr Pinskier : Yes. This is a critical issue, and thanks for raising it. We've got a current situation which is clearly quite bizarre, in that most of the world has moved on in terms of accepting electronic transfer of information. In banking now, if you want to move money around, you pull out your phone and you push a few buttons and, magically, money moves between accounts. If you come to my practice and I want to write you a prescription—doesn't matter who the prescriber is, whether it's a doctor, a dentist or anybody else—I can print it out electronically, but, at the end of the day, I have to sign it with a wet signature. It's a crazy system where I get a national prescriber number, I prescribe predominantly pharmaceutical drugs for the Pharmaceutical Benefits Scheme, but I'm regulated at a jurisdictional level by the drugs and poisons act, and they mandate a wet signature on every prescription. We have all the technology to transfer information electronically. We have a prescription exchange service—what's known as electronic transfer prescription. I can move your data up to Medicare. I can move it into My Health Record. All that is is a facsimile of a medicine; it is not a legal prescription. The only legal prescription is one that I put a wet signature on. There is no reason why this cannot be addressed and resolved immediately. The technology exists. It's a question of the governments, COAG—I know they're meeting here today—sitting down and working out a national solution where they agree to national standards.

CHAIR: Yes. I can't disagree with you. Dr Bonanno and Mr Nguyen, I have some questions for you. You've made some points in your submission in relation to infection control obligations that are imposed on you and particular state variations. Could you elaborate on that, please?

Dr Bonanno : I will give you an example. I practice in the ACT—I've just come from work this morning. As part of our national registration we have to comply with infection control requirements as mandated by the Dental Board of Australia. Then we have ACT Health, who expect us to have an infection control licence. On top of that we also have practice accreditation, which at this point is voluntary, but it is looming to become compulsory. That's where the Australian Commission on Safety and Quality in Health Care will look at infection control accreditation. Then you have other bodies, for example, the NHMRC, which has its own infection control standards. Then you have Australian Standards 4815 and 4817. So we're really being bombarded from a number of different directions in this regard, and these bodies don't seem to talk to each other. The thing is, they are at liberty to have their own interpretation of what these standards mean. We're talking about the practical application of these standards at the practice level. The other accrediting agencies will say, 'The dental board is really looking at your infection control behaviour as a practitioner, whereas the other standards are looking at the practice environment.' That is just a nonsense, because the environment facilitates your behaviour as a practitioner. It's all related. So, we don't accept those arguments. I raise that because you will probably hear that if you're investigating that further. The point is that if you have national registration, that's the enabling part. They are the rules about how you behave and how you practice appropriate infection control. So, we're over-regulated in that area. I don't think different jurisdictions have infection control licensing, but you have the state authorities, who have their own interpretation of these things.

Again, you have too many tiers of regulation, and, as I said, with looming practice accreditation, and that body unfortunately doesn't communicate well with the professions. I don't know what your experience has been with the RACGP, Dr Pinskier, but the commission is—

CHAIR: Who is going to do the practice accreditation? Who will be doing it?

Dr Bonanno : There is engagement of an independent accreditor.

CHAIR: But who will they be acting for?

Dr Pinskier : The RACGP was the first of the professional colleges to establish accreditation, so we develop our own standards. But back in 1996 an independent organisation called AGPAL was established—Australian General Practice Accreditation Limited. It is owned the profession and peer surveyors, GPs, practice managers, and those who do the accreditation. We are under threat. The Australian Commission on Safety and Quality in Health Care wants to take that over—again, adding another level of bureaucracy.

The infection control issue is an important one. It is one we have been working to try to simplify for many years. It's part of our standards. The risk is that if you make it too complex, people either stop doing procedures, because it's too hard, which means you end up having have to go to tertiary facilities to have them done, or they buy single-use disposables and that ends up in landfill, neither of which is a great option.

CHAIR: In the veterinary sector, the veterinary boards run the accreditation program as well. I was wondering who you are anticipating will be doing the accreditation or have authority in relation to the accreditation of dental practices?

Dr Bonanno : That's where we put in our submission that we think the self-regulatory model is the way to go. We have our own version of the standards and we actually put out our own infection control manual, which is the only up-to-date infection control guideline for dental practitioners. That's something that's referenced by the Dental Board of Australia.

CHAIR: Who is 'we'?

Dr Bonanno : The Australian Dental Association.

CHAIR: You are putting out your own guidelines and recommendations and so forth?

Dr Bonanno : That's right.

CHAIR: It would be quite nice if that took precedence over these various other bodies, wouldn't it?

Dr Bonanno : That's right. To expand on that, we have an infection control committee. The membership of the committee are some of the best minds in dentistry, who are up to speed with the latest infection control issues and advances. Therefore, we're able to have a document that is a live document. We can amend it at any time we like and it is available to all of our members at any time.

CHAIR: Yes, I agree, and it sounds very attractive from a regulatory point of view. If we were able to get the other state bodies, in particular, to relinquish their interest in it and leave it to that process that the ADA is running, that would be progress, I would have thought.

Dr Bonanno : I totally agree.

CHAIR: With the previous witnesses, we talked a bit about X-rays or radiation. Do you want to add anything to it, or do you think the field was covered with the previous witness?

Dr Bonanno : I listened to what Mr Williams had to say. What I would say in relation to registered dentists is that the ability to take X-rays is part of my undergraduate training, but then apparently, over and above my dental registration to practice dentistry, I need a separate licence to actually use an X-ray machine.

CHAIR: To press a button—that's right.

Dr Bonanno : That's right. If you look at some of the background information we have to provide in order to receive a licence—we're talking about a licence for diagnostic dental radiography—we have to spell out that we're taking X-rays to facilitate a diagnosis or as part of the whole treatment process. So we have to justify to a non-clinical authority why we're using these machines in the first place. It just seems that there are bodies that don't communicate with each other. As I say, that's a cost. That's a licence that we need to reapply for.

CHAIR: Yes. I've always been mystified as to why there is some regulation of your use of radiology equipment that appears to take an interest in your clinical judgement and your use of X-rays for your professional activities. You could argue, perhaps—I'm not sure I would, but others would—that perhaps there's some regulation to protect staff so you don't have leakage of radiation and various things like that. But why they should take some interest in you as a professional dentist and your use of radiology equipment is mystifying. Would you agree, or have I got it wrong there?

Dr Bonanno : You've hit the nail on the head there. Just in relation to radiation safety et cetera, there is separate licensing for ownership of the machines. I think that, from the perspective of ensuring that the machines are maintained and that there is an awareness and there are protocols in the practice environment to ensure that radiation hygiene is practiced, that's okay. But, as I say, you want uniformity nationally. We had national law to make dental registration national—over 600 pieces of legislation pared down to about 80. That made sense. Why couldn't we do it with everything else? Why have we gone from state based registration as health practitioners, singling that out, but left everything else state based? I have experience, having served on the first Dental Board of Australia, so I've been involved with the work that was required to eliminate the variations in the different registration categories. A lot of work was done there, but the thing is that we have a system now which is working better as it evolves, so there's no reason why that can't happen with these other areas of duplication that we've been talking about this morning.

CHAIR: I have one more line of questioning, but I will go to Senator Burston.

Senator BURSTON: Do the 3D imaging machines emit radiation when they put it through a 3D printer for dental caps and so on?

Dr Bonanno : Sorry, you're talking about two different pieces of technology. You're talking about the machines which manufacture crowns, not the 3D X-ray machines.

Senator BURSTON: My dentist has one. Instead of outsourcing it, he—

Dr Bonanno : Yes.

Senator BURSTON: Is that regulated in a similar way?

Dr Bonanno : No. You don't have the same sorts of issues with those.

Senator BURSTON: Dr Pinskier, going back to the 20 per cent admin for GPs, how does that compare with specialists?

Dr Pinskier : It may very well be similar. I'm not qualified to speak about the specialist area. It may very well be similar. As medical practitioners we all face the same regulatory constraint. I might just read you something from an article by a GP in The Age yesterday, 'GPs need to be recognised as the specialists they are'. It is quite timely. She said:

I reached boiling point last week after spending an hour on the phone trying to get a taxi subsidy for one of my patients. There are plenty of boxes to tick to get a taxi subsidy, but specifically you need a specialist letter confirming you cannot walk 20 metres without assistance. So what about a woman in her 70s with multiple problems who can usually walk 100 metres slowly, who has just had a major operation?

This case was a medical emergency. My patient was expecting to be discharged from hospital within 48 hours. She was worried about her ability to shower alone, let alone walk 20 metres or drive herself to her dialysis treatment, which she needs three times a week to stay alive.

Her story had been clearly outlined to the paper-pushers. But they still asked me for a specialist letter. So which specialist? The kidney specialist … the joint specialist … or the surgeon … I went with the surgeon—and wrote it for him, emailing it to his secretary …

The RACGP has been running a campaign, and you've probably see this at all the airports and on trains and buses: 'I'm not just a GP. I'm your specialist in life'. As part of the move to the national boards, the Medical Board of Australia, or APRA, GPs are recognised as specialists, but in this particular example, at a state level, the GP is not recognised as a specialist.

Senator BURSTON: I had a similar thing. I had a CT scan on my stomach, and they picked up a spot on my liver. I was required to have an MRI. My GP complained, saying, 'No, I'll have to refer you to a specialist. You might have to wait three months. Or I can refer you and you can go and pay the full freight.'

Dr Pinskier : Correct.

Senator BURSTON: He can do a full MRI referral for a knee but not for an organ. Why is that?

Dr Pinskier : We have a bizarre set of regulations that are essentially historically enshrined. GPs can order all sorts of tests that are radiation based, but, when you want to do a more modern test, such as an MRI, all of a sudden you're restricted because there may be a cost differential to the Commonwealth. We've argued with successive governments that there are all sorts of solutions to work around that, but it's a challenge to get it through the system.

I have a very, very good friend who was a Canberra based journalist and who worked here for many years. In Canberra he was unable to get access to an MRI, and, eventually, when he got his MRI, he had three lesions on his liver and was subsequently told, 'Go away. You're going to die.' This was less than a year ago. I got him down to Melbourne, I got him into the Austin program, and he got a liver transplant six to nine months ago. He has subsequently lost nearly 80 kilos. I'm going to meet him in half an hour. He's probably known to all of you. We had a function about five months ago at the Melbourne Press Club, with Derryn Hinch and my friend, called Donating the Gift of Life. He talked about some of these issues—the fact that he couldn't get an MRI on the MBS and he ended up paying about $400 out of pocket. It's exactly the same problem. Because people don't get timely access because there are all these regulatory differentials, some of which make no sense, we expose people to unnecessary radiation. I order a CT because I can. You get radiated, and guess what? I refer you to the specialist and you get your MRI. It is really crazy.

Senator BURSTON: I paid $500 and saved three months time. It didn't save my life because it was benign but it's a perfect example. Thank you.

CHAIR: Let's not even go down the medical marijuana path. That is an absolute snake pit.

Dr Pinskier : Let me quickly talk about real-time prescription monitoring. We understand we have a problem with schedule 8 drugs of dependence—overuse. It's a problem. We have talked about establishing a national system for real-time prescription monitoring. Successive federal governments have provided funding to develop a national system; states have decided largely to go out on their own. Victoria's implementing its own real-time prescription monitoring system. That will work if you are in Victoria, but guess what? When you're on the border, it won't work. We'll have different ones in different systems and we'll have to connect up all of those to our system, and, if we don't check it once the legislation becomes law, we're in breach of the legislation. How do you do that in different states and territories all at the same time? Harmonising the rail gauge—having national standards and national implementation of processes—would provide benefits to everybody.

CHAIR: Dr Bonanno and Mr Nguyen, you also had quite a discussion in your submission about the registration process and re-registration for dentists. One thing that stood out was the legal obligation to have indemnity insurance. What are your thoughts on that? There is a market for insurance. If you don't have insurance, you'll lose all your assets if you lose a case. Should the law intrude in that area, or do you think it's wise to have indemnity insurance?

Dr Bonanno : I was on the Dental Board and this was something that we discussed. Previously it wasn't compulsory, but the point is that, if it is compulsory, it benefits everybody. The fact is that medical litigation does exist. Problems occur. The board is there to protect the consumer; it's not there to protect the dentist, the doctor or whoever. This was introduced across all the boards. The whole idea is that the consumer is protected. That means that, if there is an adverse outcome and there is a finding against the practitioner, the patient is covered. Their costs and any compensation they are due is covered. It would be unreasonable not to support that.

From the other perspective, the practitioner is then covered as well. Of course, that's going to have an impact on fees, but that's always been the case. I don't think the fees in dentistry have reached the level they have in medicine, especially in the specialist areas. I think that's a commonsense situation. Understanding that it protects both sides means that really it's a no-brainer.

CHAIR: Your submission says 'annual renewal shouldn't require confirmation a practitioner has maintained current indemnity insurance or other requirements outlined above'.

Dr Bonanno : We are talking about having to sign a document saying that you are current. The submission isn't arguing that the indemnity is not necessary. It's just about having to state the obvious on an annual basis. We would support, say, triennial registration, as opposed to annual.

CHAIR: Does that corresponds to the CPD obligations?

Dr Bonanno : The CPD obligations are triennial.

CHAIR: What's the situation with GPs? Do you have annual renewal or triennial?

Dr Pinskier : We have annual renewal with the Medical Board. We have a triennial continuing professional development program.

CHAIR: What is your view on what Dr Bonanno just said?

Dr Pinskier : I would strongly support it. I worked in an area where we didn't have compulsory insurance. In the early 2000s we went through the medical indemnity crisis. The government of the day stepped in and capped insurance at eight per cent, from my memory. We've seen some substantial improvements. What we don't have, though, is transparency around activity. So it's not clear to me as a provider how my premium is set. We have seen a massive change in premiums from being a single premium to community rated, but we don't get feedback from the insurance providers and so we don't really know what it is we can do to improve our performance. It's not even clear whether doing continuing professional development makes a difference or not. We need more evidence to support how the premiums are set and find out what we can do to actually reduce our risk.

CHAIR: So it's not a one-size-fits-all premium for GPs?

Dr Pinskier : It used to be one size fits all.

CHAIR: Not now?

Dr Pinskier : Not now. Each of the providers sets their own premiums. It is unclear to me as a user and payer how that premium is actually established and what I can do to mitigate my risk. Unlike my housing insurance, where I can do things—I can put locks on the front door and windows and install alarms—it's not exactly clear.

CHAIR: Can you shop around?

Dr Pinskier : You can shop around, but generally people tend to stay with the same provider because it's on a claims made or claims incurred basis and, if you change, there is a risk that you may not be covered. You may have a gap. We know with standard insurance you are covered from the date that it starts to the date the policy expires. But, with medical indemnity, the claim may have occurred eight or 10 years ago. So people tend to stick with the same insurer.

CHAIR: That's an interesting issue.

Dr Pinskier : Can I make one more point about the registration. I fully concur with ADA on this. We have a major problem in the way that we register and manage all healthcare practitioners. We have that many numbers, it's bizarre. To become a healthcare practitioner, once you graduate, you get registered with AHPRA and get a number with AHPRA. That gives you access to an AHPRA portal. The AHPRA number then gets transferred up to Medicare and you have to apply for a Medicare number. For every location I work in, I get a separate Medicare number. If I don't maintain them, they will sit there forever and grow. In 2010 we established the healthcare identifier. I was part of that program. So everyone known to AHPRA has a Healthcare Provider Identifier-Individual, known as a HPI-I. Every practice that wants to connect to the national system now gets a HPI-O, Healthcare Provider Identifier-Organisation. So we talk about hunting 'hippies' and 'hippos'! We have numbers now that are unique for organisations and individuals. We still have the Medicare provider numbers. The Productivity Commission looked at this issue about six or seven years ago and recommended that Medicare provider numbers be streamlined. We would strongly argue that, if we have national numbers that are healthcare provider identifiers, those numbers should be used as part of the claims and payments system as well.

I also have a prescriber number. I have no idea why I have a prescriber number. That is a unique number issued by Medicare. The only time it appears is on my prescription pad. Why can't I use my healthcare provider identifier for that? So there's a whole lot of bureaucracy. Just to register doctor in the system in my practice takes 15 forms. That is 15 forms to complete just to get the doctor into the system. I have provided these to Medicare, the department, the digital healthcare agency and other organisations. Everyone says, 'Yes, that's terrible,' but nothing ever gets done about it. We have a great opportunity as part of the digital transformation and the current review of Medicare's claims and payments back-end processes to streamline all this and reduce it down to the minimum number of numbers that we need to run an efficient and effective system.

CHAIR: You just summarised the red-tape issue in one sentence there—well, without a breath, anyway! Thank you very much, gentlemen. Your evidence was very much appreciated.

Proceedings suspended from 10:31 to 10 : 45