Note: Where available, the PDF/Word icon below is provided to view the complete and fully formatted document
 Download Current HansardDownload Current Hansard   

Previous Fragment    Next Fragment
Thursday, 17 November 1983
Page: 2915

Mr CARLTON —In this debate I am responding on behalf of the Opposition to the second reading speech of the Minister for Health (Dr Blewett) on the Health Legislation Amendment Bill (No. 2) 1983. The Bill draws together amendments to four Acts in a number of distinct areas. The most significant changes are in the area of aged care, mostly relating to nursing homes. I shall return to that subject after I have dealt with the other areas covered by the Bill. A number of the changes arise from alterations to social security arrangements that require amendment to health legislation. These include:

The restoration to unemployed school leavers of their entitlement to a health care card during the first six weeks after they leave school, before they draw unemployment benefits. This entitlement was inadvertently denied to them by previous legislation, but the anomaly was corrected administratively, so that this measure is a tidying up provision.

The removal of the discrepancy between the health care card income test for sole parents and that for married parents with the same number of children.

The issuing of health care cards to persons in receipt of unemployment and special benefits for a period of 12 weeks instead of the present period of two or three weeks, estimated to give net savings of $3m after allowing for the cost of some services obtained free outside eligible periods.

The exclusion of the new remote area allowance from the definition of income for the purposes of the health care card income test for low income earners.

Permitting the Director-General of the Department of Social Security to obtain information from a third party which may affect the entitlement of another person to a health care card.

Bringing persons in receipt of the new spouse carer's pension within the category of eligible pensioner, and therefore entitled to whatever fringe benefits are available to eligible pensioners.

The Opposition supports all these measures, together with the proposed changes to the isolated patients travel and accommodation allowance scheme-which we call IPTAAS-and the relaxation of referral procedures for patients with cleft lip or cleft palate. No major issues of policy are involved, but people will be assisted in needy situations, and administration will be improved. Similarly we support the amendments to the Medical Research Endowment Act to bring the administration of the Medical Research Endowment Fund into line with more modern accounting and auditing requirements. I must confess to being a little mystified as to why it should take nine months rather than six months to prepare and present the report on the fund to Parliament, but I am reluctant to question the progenitive processes of the biomedical research community, given its awesome assembly of brainpower. Perhaps it has more to do with the bureaucratic machinery with which it is of necessity encumbered.

In passing I would like to acknowledge the bipartisan approach to medical research funding adopted by the present Government. I am sure the Minister will be pleased to hear me say one or two nice things about his administration. Maybe it has something to do with the eagerness of the Prime Minister (Mr Hawke) to impress constituencies outside his biennial party conference. It should be noted that the Government has met Mr Malcolm Fraser's policy speech commitment to increase the grants for medical research. This is in marked contrast with the Government's lack of success in meeting its own policy speech commitments. For example nine out of 10 Australian families are still waiting to pay less for their health care and to receive their promised tax cuts.

A matter of interest and possibly concern to pharmacists is the proposed repeal of section 91 of the National Health Act, which imposes restrictions on the number of friendly society dispensaries in each State which are allowed to supply pharmaceutical benefits to members of the general public. I am informed only eight limited approval friendly society dispensaries exist, located in two States, South Australia and Queensland. I can understand the concern of community pharmacists in areas close to these eight dispensaries, as there would be a fear of loss of business. However normal businesses compete successfully with co-operatives in a number of areas of the economy, and it is therefore difficult to justify imposing trading restrictions on co-operatives in this particular area.

Nonetheless I would like to warn the Government that the Opposition would vigorously oppose any further action by the Government to extend any special privileges to pharmacy co-operatives that would enable them to compete unfairly with independent private enterprise pharmacies. We have a firm commitment to small business, of which community pharmacies are a prime example. This Labor Government is highly suspect in its tendencies to use community health centres and hospital pharmacies to undermine private pharmacies. We would regard special privileges to co-operatives in a similar light.

I turn to a totally different subject. The amendments to the secrecy provisions of the National Health Act to bring them into line with those of the Health Insurance Act. The inability of the Department of Health to provide certain types of information to courts and properly constituted professional hearings has hindered the pursuit of quite legitimate and necessary inquiries into fraud and malpractice. A number of examples arose during my period as Minister, and I indicated at the time my concern over this anomaly. There are, I believe, adequate restrictions on disclosure to protect the privacy of providers and patients without shielding wrongdoers. Another change in a related area is the proposal recommended by the Joint Committee of Public Accounts that medical or optometrical practitioners appealing against an unfavourable decision following an inquiry into overservicing will have to meet their own costs. It does seem rather unfair that this should apply in the case of a successful appeal, but we are informed that this provision follows the usual procedure for appeals to the Administrative Appeals Tribunal, so the Opposition will not oppose it. I understand that under the Administrative Appeals Tribunal system costs can be met under certain conditions. Perhaps the Minister will examine the matter to ensure that the rules are exactly in line with those applying to the Administrative Appeals Tribunal.

I turn to the principal area of legislative change with which this Bill is concerned, the important and sensitive area of aged care. It is difficult to know how to approach the set of changes to the nursing home program outlined in this Bill. In themselves they are not sufficient to gauge the direction of change envisaged by the Government. They could be leading in a satisfactory direction, but they also have within them some signs that one bureaucratic nightmare is being replaced by another. Given the ideological bent of this Government and the natural inclinations of its advisers I fear the latter.

At least on one thing the Opposition and the Government are in agreement: The need for change. The House will recall that as Minister for Health I expressed grave dissatisfaction with the existing order. In conjunction with my colleagues Senators Chaney and Messner, the then Ministers for Social Security and Veterans ' Affairs respectively, I set up a working party to carry out a thorough review of the aged care system. I also appointed a consultant within the Department of Health to examine in detail the systems of government subsidy for nursing homes. The Government will now have the benefit of the former study, although ominously the Department of Health expunged the consultant following the change of government, despite the non-political nature of the appointment and of the person concerned. I fear that this action has signalled a return to the Byzantine approach previously being followed by the Department in this area, and there were signs in the Minister's statement on Tuesday relating to fraud in nursing homes that this is the case. If so, God help the Minister and the Government, as they will be led down paths of unnecessary complication and bureaucratic interference with the voluntary and private sectors and in the end, as usual, the customers and taxpayers will suffer.

The Minister says quite bluntly in his second reading speech that we have in Australia very ade- quate provision of nursing home accommodation, but inadequate community care services and hostel accommodation. Later on in the speech he describes his first steps towards 'achieving more meaningful assessment procedures' for determining the actual needs of the aged and disabled for various types of care. The assessment will address their medical, social and emotional needs. I agree with the Minister that this assessment cannot be carried out effectively by Commonwealth medical officers who do not, under the present system, have any contact with the patient. They only look, at the moment , at a form signed by a general practitioner, and they look at it in their office without seeing the patient. How on earth then, on the basis of existing assessments, can the Minister have the slightest idea as to whether or not Australia has, to use his words 'very adequate provision of nursing home accommodation'?

I very much fear, from the Minister's speech, that he has prejudged this question. The mention of the cost of nursing home accommodation at the very beginning of his speech suggests that he is led to believe that to maintain a tight squeeze on nursing home accommodation and to rely on expanded hostel and community care facilities will both contain the cost problem and serve the aged and disabled better. Great caution must be expressed about such a conclusion. There is strong evidence from the United States of America that greater reliance on community care does not work out cheaper than institutional care. Also there is a limit to the capacity of families and friends to sustain the physical and emotional burdens of caring for the aged and disabled at home. Striking the correct balance between public demand and the legitimate call on the taxpayer is devilishly difficult in a non-market situation such as this, and the instruments currently available to the Minister, or even those available in the medium term, do not enable him to determine the balance he so confidently strikes in the opening section of his speech.

Let us be quite clear about the concern of the Opposition in this area. The assessment procedures proposed by the Minister must not become instruments of coercion to squeeze the damand for nursing home places into a pre-determined mould, a mould set primarily by budgetary considerations. We will be watching these developments closely. The proposed new procedures for dealing with nursing home applications are subject to the same kinds of doubt. The power to decide on applications is transferred in this Bill from the permanent head to the Minister . We have no quarrel with that. The power will be delegated anyway. All the change means is that decisions on applications can be reviewed by the Administrative Appeals Tribunal, and that is welcome.

We also welcome the decision to table the principles for determining approvals for new or additional nursing home accommodation in the Parliament. It is to be hoped that there will be adequate consultation with the voluntary and private sector providers of accommodation and with members of this Parliament in the formulation of these principles. Members in this House in particular have a wealth of knowledge about the needs of their own community and of the potential contributions of community groups to the care of their own aged and disabled. Country areas have special problems in trying to provide local accommodation and are usually prepared to raise funds to build and maintain facilities that might not be regarded in isolation as strictly economic.

Mr Fisher —Hear, hear!

Mr CARLTON —The honourable member for Mallee acknowledges that this is the case from his own personal experience. It is very important that the new procedures do not squeeze out these community initiatives which might take some years to develop and might not be able to respond instantaneously to a newspaper advertisement calling for applications in a particular area which is a provision of this new Bill. My Liberal and National Party colleagues will be watching these developments closely to ensure that community needs and aspirations are not crushed by the bureaucratic machine. The honourable member for Lyne (Mr Cowan) who is in the House listening to this debate will acknowledge that there is a very great concern in country areas about the capacity of rural communities , which have a great willingness to contribute in this area, to be able to be fully involved in this particular process.

Mr Cowan —That is right, and the conducting of administration.

Mr CARLTON —That is exactly right. Also, the honourable member for Paterson (Mr O'Keefe) has spoken to me about this matter. Unhappily I found this bureaucratic problem arising during my own period of administration as Minister for Health and I was seeking ways to overcome it in conjunction with State Ministers because they were also involved in this. As the Minister acknowledges, there is a need to decide these principles for new accommodation as soon as possible as the situation has been frozen for some time now and many communities and families are getting desperate. Let us do it quickly, but let us also get it right.

Finally I would like to deal with some of the problems of those who provide nursing home accommodation in the private sector. I know that this Government has an inherent bias against the private sector, but I also acknowledge that the 1973 fee control system for which governments of both political colours must accept responsibilities turned out in the end, as all price control systems usually do, into both a lottery and a nightmare, with increasing proportions of booby prizes awarded to the participants. There is no doubt that some private nursing home proprietors did extremely well out of the scheme. It is equally clear that others were cheated and are still being cheated. There is no way that the administrative machinery of the Department can tell with any certainty which is which. Faced with rising costs and a crippling administrative burden, the Department developed a siege mentality on fee setting. The industry retaliated by increasing the number of appeals against adverse fee determinations, thereby compounding the processing problem.

I must confess that in all my years of management experience, in private industry, in my own Party organisation and in the public sector I have never seen a tangle such as this one. I think my friend the honourable member for Grayndler (Mr Leo McLeay) will acknowledge that because he was the Chairman of a sub-committee of the House of Representatives Expenditure Committee which looked into this matter. I certainly regarded it as the most difficult political and management problem I faced as Minister. I regret that I was not given time to sort it out. The people spoke on 5 March and decided that I was not to be the person to do it and my friend opposite, the Minister, was given that task. It is also illustrative of the kind of situation that is all too prevalent in our system of government in which overworked Ministers are advised by civil servants with very limited management training, however substantial, as it often is, their technical expertise or intellectual qualities may be. There are ways of running billion dollar programs well, but our Public Service does not, as I have observed on so many occasions and will continue to do so until we sort the problem out, prepare its managers adequately to deal with these problems.

As an aside, honourable members might be interested to know that the problem is not confined to Australia. In August this year I had the opportunity to attend a three-week course for senior managers in the United States Government at the John F. Kennedy School of Government at Harvard University. I was able to swap experiences with over 100 career officials, political appointees and military leaders facing similar problems in the United States. There are solutions to these problems, but they require a substantial reform of the Public Service of a kind not really addressed adequately, for example, in the Coombs Royal Commission on Australian Government Administration. However I will not dwell on this broader subject. Let me return to the question of fee determinations for private nursing homes.

At first sight this Bill appeared to remove the statutory requirement on the Department to deal with a fee change application within two months. The removal of sub-section (1) of section 40AE of the National Health Act and the curious wording of the proposed new sub-section (1D) of section 40AD seemed to indicate that this spur to departmental action was to go. Although it was hardly ever met in practice due to administrative overload, it stood as a reminder that the world was not supposed to be mad, even if day to day it seemed to have taken leave of its senses.

The Opposition decided to move an amendment to restore this requirement, a quixotic gesture some might say, but at least symbolic of our concern to restore some sanity into the situation. However, after lengthy examination of the twisted entrails of this Bill, assisted by officers of this House and drafting counsel, assistance for which I am deeply grateful, we have concluded that the new sections 40AD and 40AE, at least in theory, give nursing home proprietors a miniscule advantage over the present arrangements.

What happens now is that a proprietor requesting a fee increase puts the application into the Department where it can languish well beyond the statutory limit of two months, and there is precious little the proprietor can do about it . Eventually the Department makes a decision. If it is not to the proprietor's liking, a not uncommon occurrence, the proprietor can ask for a review by the Minister. The Minister then seeks the advice of a Nursing Homes Fees Review Committee of Inquiry. There are literally dozens of these committees and the Minister for Health has to be very careful about remembering where they are, who belongs to them and who does the work. In bureaucratic machinery of this size an enormous number of people give almost voluntary service; they are paid some compensation, but they give almost voluntary service to carry out tasks which are of great complexity and, I suspect, in many cases relatively unrewarding. I pay them a very great tribute. The Nursing Homes Fees Review Committee of Inquiry then makes a recommendation to the Minister. The Department, in passing this recommendation on to the Minister, adds its own recommendation, which often conflicts with that of the Committee. Often it recommends a 50 per cent discount .

It gives me no pleasure to report that, on the basis of my experience as Minister, this process is heavily loaded against proprietors and in some cases results in injustice. Endless delays can occur in the review process. The Committee of Inquiry has to rely on the same administrative processes that originally dealt with the application, and delays can extend over many months. Ministers, I found to my dismay, can be virtually powerless in trying to speed up this process. The procedure seems to have a life of its own, impervious to outside interference. In fact if honourable members want to examine this matter in great detail I refer them to the diaries of Richard Crossman; they are most illuminating. It is quite possible for proprietors to go out of business while all this is going on or, more likely, not going on.

This Bill continues to exclude the fee determination process from Administrative Appeals Tribunal review, so proprietors will continue to have no redress short of legal action once the Minister has made his determination after a review. They can go to the courts, and some have. If honourable members doubt my comments about the rank injustice of this system, they have only to read the judgment in one of the more celebrated of these cases to have trenchant judicial confirmation of my views.

As the Minister has foreshadowed a change in this system to one of program grants, the Opposition has refrained from moving an amendment to bring fee decisions within the ambit of the Administrative Appeals Tribunal. We will, however, watch closely to see whether the program grant system will act to the disadvantage of voluntary bodies or private enterprise in nursing home provision . If it does we will oppose it strongly, as most of the innovative developments in institutional aged care occur in the voluntary and private sectors. They must continue to be the main providers.

The minor improvement in this Bill in regard to the fee question, which we eventually discovered by our reading of the Bill, is that it enables a proprietor to force a rejection of an application from the Department after two months, although the proprietor cannot force a considered determination. However , he or she at least has the opportunity to proceed with the review process once the rejection has been forced. There is no guarantee, of course, that the review process will not be subjected to delay and interference by the Department as it is now. I hope that the Minister will take steps to make that process work in the way it is intended to work. I tried.

Overall, therefore, the Opposition offers no objection to the provisions in the Bill, although the House will note that our approval is heavily qualified and conditional. We will watch nervously on behalf of consumers, taxpayers and providers to try to ensure that they are not sacrificed to democratic socialism in practice. After the experience of the Medibank exercise, we confess to being very gloomy about the prospects.