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Tuesday, 19 August 1980
Page: 45

Dr BLEWETT (Bonython) - The National Health Amendment Bill 1980 and the Nursing Homes Assistance Amendment Bill 1980 are two small Bills in the health field. Although they are minor Bills Opposition members are rather thankful that we get any health Bills to debate at all. It is interesting to note that these are the first two Bills introduced by the Minister for Health (Mr MacKellar) in the nine months during which he has been Minister for Health. One could accuse the previous Minister for Health (Mr Hunt) of being hyperactive. He produced a new national health scheme every year. One year he produced three national health schemes. He was often charged with being too active. That is certainly a charge one cannot bring against the present Minister for Health. His inactivity suggests, of course, that he is in charge of a functioning and efficient health care system, when instead he presides over one of the most inefficient, one of the least equitable and certainly one of the most confusingly complicated health care systems in the Western world.

Running the foreign affairs of this country no doubt minimises the attention that the Minister for Health can give to health issues. I suppose we should be grateful to the Minister for the little segments of attention that he gives to health, given his visits to France, to West Germany, to Britain, to the United States of America, to Fiji, to Botswana and to Zimbabwe, all in his brief nine month tenure as Minister for Health in this country. It was the Prime Minister (Mr Malcolm Fraser) of this country who promised us in 1975 that he would not give us tourist Ministers. In Mr MacKellar he has given us a part-time locum as Minister for Health.

The two Bills now under discussion are the National Health Amendment Bill and the Nursing Homes Assistance Amendment Bill. The first objective of these Bills is to broaden the range of information that can be required from proprietors of approved non-government nursing homes. The

Department of Health can now require the furnishing of audited accounts from approved nongovernment nursing homes and the keeping of further records over and above those at present required under the National Health Act. The second objective is to introduce penalties for failure to provide the required information. The Bill increases the penalties relating to the provision of other information. Furthermore, penalties for nursing home proprietors deliberately providing false or misleading information have been increased from $200 or imprisonment for six months, to $10,000 or imprisonment for five years. Thirdly, the Bills introduce an alternative power - the power to suspend a nursing home approval as an alternative to the power of revocation. Revocation was a rather drastic and therefore rarely used sanction; and it seems to the Opposition that the power of suspension is a much more realistic option to be used for breaches of the National Health Act in relation to nursing homes. In introducing the power to suspend the approval of a nursing home the Government has rightly protected- the patients concerned. The Commonwealth benefit or the nursing home fund benefit will not be payable during the period of suspension, but the proprietor will be required to deduct those amounts from the fee to be charged. Thus the proprietor, not the patient, will bear the financial penalties of suspension.

The Nursing Homes Assistance Amendment Bill simply applies the penalties for deliberately providing false or misleading information to the deficit-funded nursing homes, mainly nursing homes run by non-profit, religious and charitable organisations. These organisations are already required to provide an annual budget and other detailed information. Unfortunately, there have been no previous penalty provisions for false and misleading information, and these have now been included in the amending Bill.

The Australian Labor Party does not oppose these two minor Bills. Indeed, we are gladdened by the sight of Liberals extending control and regulations over what they call private enterprise. We in the Labor Party believe that there is an inherent conflict between the provision of humane services in nursing homes and private profit from nursing homes. Because of this inherent conflict there is a need for tight public monitoring of profit-based nursing homes in this country. Again, the taxpayers subsidise nursing home benefits to the tune of something like $200m a year, and the Government, as guardian of the taxpayers' interests, needs to have effective public controls. Therefore we welcome the legislation that has been introduced.

However, there are two general comments we would make. Firstly, these measures fiddle at the edge of what is becoming a set of accumulating problems in the nursing home sector. Secondly, there is no sign in the Minister's speech of any vision of appropriate health care structures for the aged, no overall view of how private nursing homes should be fitted into a total and appropriate infrastructure for the elderly. I want to give four instances of the kinds of problems that are appearing in the nursing home sectors and which I think require immediate attention.

The first arises from a comment by the Minister for Health in his second reading speech, when he said:

Benefit levels are reviewed annually and are set at levels in each State which, with the rninimum statutory patient contribution, wholly cover the fees being charged for 70 per cent of beds in non-government nursing homes - excluding deficit financed homes- at the time of the review.

Of course, that 70 per cent cover occurs at only one brief point in the year and is very quickly eroded. I have a recent survey from the National Standing Committee of Nursing Homes. I realise that some qualifications have to be entered about it. It is a partial survey and is not totally comparable. Nevertheless, the figures reveal that, as at mid-1980, in Queensland only 37.7 per cent of beds are now covered, in New South Wales 38.8 per cent, in Victoria 42.3 per cent, in Tasmania 21 per cent, in South Australia 58 per cent, and in Western Australia 53 per cent. That is, the 70 per cent cover of beds is eroded rapidly as a result of increases in costs, which are then approved in the nursing homes. It is misleading of the Minister to proclaim that benefit levels wholly cover the fees being charged for 70 per cent of beds in nongovernment nursing homes without acknowledging at the same time the significant drift that occurs through the year.

I recognise that it is not an easy problem to solve. Certainly the Labor Party has no desire to swell the profits of private nursing homes on the ostensible grounds that it is benefiting the patients. If honourable members look at the Australian Financial Review they will regularly find advertisements listing nursing homes as worth while' or 'valuable' form of investment. In New South Wales recently a private nursing home of 845 beds was up for sale for $ 11.5m, or some $13,600 per bed. Those bed costs are ultimately to be met through Commonwealth nursing home benefits, Commonwealth funded pensions, Commonwealth subsidies, from health fund contributions, and from the patient moiety. Clearly, many of these nursing homes are highly profitable organisations. Nevertheless, while being aware of the profit issue, the significant annual drift from the 70 per cent of beds fully covered does need governmental attention. Yet the Minister's speech suggests that he is unaware of this drift. We ask him tonight: What is he going to do about this growing problem of drift in the cover in nongovernment private profit-making nursing homes in this country?

The second instance we present is the problem of the very different daily rates of benefit between the States. They vary amazingly, and seem to have been the result simply of accidental and fortuitous events. I look forward to seeing justification of the very big difference in the nursing home benefits paid in the various States. It is certainly one aspect of the problem that needs to be looked at today. The third instance is a need for more governmental action in exercising control over the level of training of staff provided in nursing homes. In Queensland the private hospital and nursing home associations are attempting to introduce a third tier of nursing in nursing homes, beneath the trained nurses and the nursing aides. The aim of this proposal undoubtedly is to reduce labour costs and therefore to increase pro- fitablility. Given this Government's track record on nurses' education, it will probably welcome this attack on nurses' professionalism and the diminution of nurses' status.

The fourth instance relates very much to the Labor Party's philosophy in the matter of nursing homes. We believe that there is a fundamental difference between public and non-profit-making nursing homes and private profit-making nursing homes. One aspect of this difference is that public and non-profit-making nursing homes are likely to give much greater emphasis to rehabilitation. On the other hand, if honourable members look at private profit-making nursing homes they will see that there is a clear financial incentive for them to secure as many extensive care patients as possible because they attract the greater benefit. We as a party favour the development of the public and non-profit-making home wherever that is practicable. I do not believe the same to be true of the present Government, and I want to exemplify the difference and raise the issue in relation to the difference of emphasis on nursing home applications in the mid-Gippsland region, where it is a matter of some controversy.

In mid-1979 a Commonwealth public servant from the Melbourne office of the Department of Housing and Construction received approval from the Victorian Health Commission and the Commonwealth Department of Social Security to build a nursing home at Wonthaggi. It is not clear how this Melbourne-based civil servant knew of the appropriateness of applying to build in the Wonthaggi area. Certainly, information about distribution of nursing home beds was not publicly available. However, his information was certainly sound because central Gippsland had a general shortage of nursing home beds. This proposal was opposed by the Wonthaggi hospital, which also sought to develop a nursing home. The hospital favoured a community-based nursing home linked to the hospital for paramedical services and day hospital care with an emphasis on rehabilitation and the return home of the patients. That seemed much more appropriate than a profit-making home which would have to charge higher fees to regain its return on capital investment.

The Commonwealth public servant, having lost that battle and acting on information not publicly available, next turned his attention to Traralgon, which was again below the accepted bedpopulation ratio. He received approval for a 30-bed nursing home at Traralgon. At the same time as this decision was made approval was given for a 20-bed hospital-based nursing home in Traralgon and a 50-bed hospital-based nursing home in Moe. But the Victorian Health Commission and the Department refused a nursing home application by the Morwell community hospital. The reason apparently was that there was a sufficient number of beds in the central Gippsland region. But one should note about this decision that none of these beds was in Morwell. The Morwell application was based on the same sound community rehabilitation principles as the one at Wonthaggi. The Morwell people argue that if the application of the particularly wellinformed public servant for a private nursing home is rejected, Morwell would be able to have a nursing home provision attached to its hospital. Thus, Traralgon would still have its beds because they are provided for at the hospital there, Moe would have its beds and Morwell would also secure some beds. All of these would be communitybased with patients near to their relatives and all would have a clear rehabilitation emphasis. This is the solution that the Commonwealth Government should be supporting in the towns of central Gippsland. I urge the Minister to follow up this issue which, I believe, is still a matter of considerable controversy in the region.

Now I turn to the other weakness which we see in the Minister's second reading speech; that is, there is no sign anywhere in it of the long run goals, the long run vision and the ultimate aim of the Liberal Government in health care for the elderly. In the remainder of my speech I wish to suggest what would be the major long run objectives of the Labor Party in the provision of appropriate health care services for the aged. We see three major goals. Firstly, we would reverse the priorities of the past and increase the public commitment to health care provision for the elderly. Secondly, we would endeavour to create in every community an infrastructure of services and institutions for the elderly so that they might choose the one most appropriate to them socially and medically. Thirdly, and at the same time, we would wish to reduce the emphasis on institutional solutions to the problems of the elderly.

Let me try to explain each of those proposals. First of all, public provision for the health care needs of the elderly has been much neglected in Australian society. There has been a tendency to leave it to the private sector and to the charitable sector. It is an issue which over the years has tended to be much more neglected than other health care concerns as a problem that could be left to the private sector. That tendency will have to be reversed in the remaining decades of this century. Greater public responsibilities will have to be accepted, not least because of the growth of the numbers of the old in our society for the rest of this century. Indeed, at present great opportunities are being provided because some of the aspects of hospital rationalisation - at another time I will devote more energy and effort to the hospital rationalisation proposals - and of public hospital provision permit and encourage opportunities to adapt and redevelop those facilities in order to serve the health needs of the elderly. So we have an immediate opportunity to move in the direction which I see in the long term as desirable.

Secondly, we need to create as far as possible - it will take time and effort - a total health care infrastructure for the elderly in every community. Too often the only choice for the old is between living at home, often with inadequate support services, and going into a nursing home. This limited choice is often both socially and medically inappropriate. As a humane society we need to provide a total range of choice for the old. I suggest that some of the main elements- I do not pretend that I can be completely comprehensive- of that range of choice are, firstly, the choice of remaining in the private home but with adequate domiciliary care and backup services; and the backup services are as important as the domiciliary care. I was most impressed with some of the developments in Western Australia where, particularly in the city of Perth, there are very good backup services, for example, help around the house to do odd jobs such as the changing of light globes for old people.

That is something we might not think about but. of course, old people living at home find it a very risky operation in many cases to change those light globes. We need these home help backup services as well as the immediate domiciliary care provision much more closely tied to health needs. So the first choice is the private home with adequate domiciliary care and backup services. The second choice is independent dwelling units; that is, people remaining in an independent situationbut with some medical support readily available. That can be organised in many different ways.

Mr MacKellar - With public funding?

Dr BLEWETT - In part. In the next 20 years there will have to be a bigger public commitment in these fields because public resources will have to help to build this infrastructure. The third choice is hostel accommodation, the fourth is daycare centres and the final choice, of course, is nursing homes. I may not have included all the possibilities but we need to create this kind of infrastructure. I am not pretending that there has not been a start to such provision or that particularly some of the church and charitable organisations, with governmental support, have not already begun to make major contributions in this field. We need to begin looking at every community to begin to see whether that kind of range of choice for the old can be provided rather than, as in far too many communities in this country, the choice being often between living in a private home without adequate support services or in a nursing home. Sometimes, of course, there is not even that choice.

Thirdly, while concerning ourselves with making adequate provision in the ways I have suggested, we need at the same time to deinstitutionalise health care provision for the old and, indeed, for most other segments of this society. There is, in fact, a considerable misdirection of public resources by government into health care structures which are often inappropriate emotionally, socially and medically and which at the same time are often more expensive than more appropriate structures. For instance, two years ago there was a very interesting report, published under the aegis of this Government, on relative costs of home care and nursing home and hospital care. I compared the costs of home care provision with the costs of nursing home and hospital care. The costs of home care health services are always much less than the costs of hospital care, as that report quite clearly shows. The costs of home care health services are less than the costs of nursing home care except for patients requiring intensive levels of service. Of course, that does not mean that it is appropriate that all our hospital care should be home care. We must then look at the medical appropriateness of each case.

The report estimates that something like 25 per cent of patients in nursing homes would in many ways be much better suited by adequate home care and that between 10 per cent and 30 per cent of hospital patients would be much more satisfactorily treated through a home care system. Indeed, if the appropriate home care services were available, a possible saving in the health bill would be of the order of $1 00m. This concerns not just a saving in the health care bill but also the fact that those home care services are probably in many cases more medically, socially and emotionally appropriate, particularly to old people.

But what we have seen, particularly in the last two years, is in many ways a decline in the home care services provided. If one looks, for instance, at the overall funding of home care services, at least in real terms there have been significant cuts. There has, for instance, been a no-growth policy - I quote a bureaucrat - applied to the home nursing service. This has meant that the number of nurses eligible for the subsidy has effectively been limited. The Meals on Wheels service, which again is a part of the whole home care service operation, is struggling partly, of course, because of this Government's policies on petrol. All are aware of the importance of the petrol bill to the whole Meals on Wheels operation.

Personal care subsidies for the frail aged have been cut. The destruction of the Australian Assistance Plan has meant that many worthwhile community projects - and the Minister can find out the details of the AAP projects that were under way - which were aimed at helping the elderly to keep out of institutions have collapsed.

We need to reverse these policies because they are basically false economies. All of these miniscule cuts - in many cases they were not so much cuts but rather increases were not made to match the inflation rate - are false economies. On the grounds of both health and expenditure savings we need to develop home care services, not cut them back. Of course, the results of these false economies and the health insurance mess are that many of the most vulnerable patients in our society are left confused. One only need talk to the old about the confusions of health insurance and about some of the blatant and appalling publicity that has been directed at them in relation to health insurance. We know that they are left confused, are often out of pocket and often find themselves in institutions which, if they had their choice, they would rather not be in.

In conclusion, I repeat the long run objects of my party when returned to power at the end of this year in relation to the provision of health care for the aged. Firstly, we will increase the public commitment in this field. We accept the expenses that will be involved in the long run in pursuit of this commitment. Secondly, there will be a comprehensive provision of health care services for the old in the community. Thirdly, we will try to de-institutionalise the health care segment for the old which, of course, will involve not only providing more appropriate health care but also, in the long run, will reduce the cost of that health care.

Debate (on motion by Mr Lloyd) adjourned.

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