Tony Zappia (Makin, Australian Labor Party, Shadow Parliamentary Secretary for Manufacturing) Share this | Link to this | Hansard source

This bill, the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017, amends the Health Insurance Act 1973 to provide for the appointment of a National Rural Health Commissioner. A National Rural Health Commissioner will, in turn, amongst other things, focus on putting in place a national rural generalist pathway. These are measures that I know have considerable support across rural health professionals and, through the commissioner, should also ensure that the rural health professionals will have an advocate for them who will, in turn, have a direct link to the minister.

It is seen by Labor as a step in the right direction in bridging the health divide between urban and outback Australia. So Labor will be supporting this legislation.

However, we believe that the legislation falls well short of what was hoped for. I particularly note that the commissioner's appointment is for a two-year period. The commissioner's position will be abolished in just three years' time, in July 2020. The commissioner will have to rely on negotiations with the health department for any staff requirements. It could also be a part-time position. Furthermore, there is a very strong emphasis on the position being primarily to establish a national rural generalist pathway, as important as that is.

Feedback from stakeholders, including the National Rural Health Alliance, also confirmed that this bill could be improved. I note, in the Rural Doctors Association of Australia press release of 8 February 2017, that the RDAA called for the appointment to be for four-to-six-year terms—that is, more than one four-to-six-year term. It is clear from the press release that the RDAA was hoping for an ongoing appointment.

Under this legislation, the National Rural Health Commissioner position, as I said earlier, terminates in 2020, without a review or any form of evaluation of the position being required under this legislation. Of course, the government of the day may choose to reconsider the termination or extend the position, but this legislation makes no provision for that whatsoever. Labor will therefore be moving amendments in the Senate that we believe will make this better legislation and which we ask the government to support.

Labor supports the establishment of a national rural generalist pathway. Queensland has now had a rural generalist pathway in place for a decade, I understand, and I have only heard positive feedback about the Queensland initiative. It would appear, therefore, that there is already a model in place that could be looked at and from which we can learn.

With adequate resourcing, there are of course many other matters that the Rural Health Commissioner may be able to address, given the many factors that contribute to health outcomes in rural and remote Australia. A national rural generalist pathway, however, whilst important, is only one of the many identified causes of disparity in health outcomes between urban, and rural and remote, Australians. A recent policy brief prepared by the Centre for Research Excellence in Medical Workforce Dynamics touches on many of the other issues that also need to be addressed. Nor should we neglect or in any way diminish the important role of other health professionals who work in rural and remote areas and who are often the first point of contact in providing health services.

As we know only too well, there is a wide disparity between health outcomes in rural and remote Australia and those in urban regions, and the statistics are very clear about that. It is well documented that those in remote communities have a higher burden of disease and a shorter life expectancy than urban dwellers. Lifespans for women and men are respectively two years and 3.4 years lower in remote areas. Suicide rates are twice as high. Chronic disease levels—including diabetes, coronary heart disease and chronic obstructive pulmonary disease—are all considerably higher. The ratio of health professionals in remote areas, particularly in specialised fields, is much lower than in the city. Dementia rates in outback Australia are also much higher than in urban regions, with a recent report indicating that around 40 per cent of dementia sufferers reside in rural or remote Australia. When you consider that less than a third of the Australian population resides in those areas, those statistics should at least sound warning bells for governments. For Indigenous communities, the gap is even wider, and I expect my colleague the member for Lingiari to talk further about that in the remarks he makes in respect of this legislation.

Rural health organisations have for years been highlighting the disparity and identifying obvious factors with respect to improving health services in country Australia. Those factors include, but of course are not limited to: the lower ratio and in some places the shortage of doctors; the remoteness, isolation and long travel distances, which create barriers for both health professionals and patients; poor communication and internet services; personal safety issues; the availability of fresh, healthy food; the harsh climate, which has its own impacts and effects on health outcomes; and the low socioeconomic status of many remote and rural communities, with many of Australia's lowest income families living in country Australia. All of these factors and others have a direct impact on health outcomes for rural and remote Australians.

There is direct correlation not just in country Australia but in all places between income levels and health outcomes. Numerous studies confirm that correlation. A snapshot of country Australia will confirm the struggles of many outback communities, some of which are on the lowest average income levels. I note, for example, that over 52 per cent of people in outer regional, remote and very remote areas do not have private health insurance. In major cities that figure is around 39 per cent—again a marked contrast. The recent 4.8 per cent increase in private health insurance rates, bringing to 23 per cent the rise in rates under this government, the Turnbull government, will make it even less attractive to privately insure. Addressing the economic disadvantage of communities is critical if we are to bridge the city-country health divide; otherwise, the divide will continue—just as it continues between rich and poor areas within large cities.

For that reason, the government's attempts to pass more costs onto patients by freezing the Medicare rebate, by cutting $1.3 billion from the Pharmaceutical Benefits Scheme, by increasing co-payments for medicines by $5, by making cuts to the Medicare safety net, by cutting $1.4 billion from preventative health and health promotion, and by cutting bulk-billing incentive payments to pathologists and radiologists will disproportionately affect rural and remote Australians. Country patients with limited incomes, already facing extra costs because of travel, will avoid doctor visits if their costs are increased, while country doctors, who have their own additional overheads to account for, will be pushed into even higher co-payments if their patient visit numbers fall. Patients and GPs both lose out. That brings me to the government's Health Care Homes trial. The RDAA has stated that rural packages should be allocated additional funding to cover the higher costs faced by rural health providers. I understand that, to date, no additional funding has been provided. I am certainly open to clarification on that from the minister, when he sums up on the debate. In my view, the trial is unlikely to provide a fair assessment of its effectiveness in rural and remote areas. The effectiveness will further be constrained because of the lack of choice or access to health professionals in some regional and remote areas.

As is well known, in many rural and remote places it is the nurses who provide frontline health services. I take a moment to make some remarks about their work. Two recent reports—one from CRANAplus and the other from the Northern Territory government—shine a spotlight on the difficulties encountered by health professionals, and particularly by nurses working in outback Australia. Almost 90 per cent of remote-area registered nurses are women, 40 per cent are over 50 years of age and the number with midwifery qualifications has almost halved over the past decade. While health workforce numbers have increased overall, the 2017 CRANAplus Remote Health Workforce Safety & Security Report found numbers in remote areas have actually declined by eight per cent. Both reports highlight the safety and security concerns of outback health professionals, listing a whole range of matters that need attention from both Commonwealth and state governments. There are multiple reported cases of sexual assault and physical violence, not just during the course of the healthcare providers' working day but also after hours in their own accommodation.

I will turn for a moment to rural scholarships, which are also a matter of some concern. This government is failing rural health students, having cut $72.5 million from health workforce scholarships. Those cuts have impacted on scholarships provided through Services for Australian Rural and Remote Allied Health—that is, the SARRAH organisation—which will allocate a reduced number of allied health scholarships by the 2017 academic year under the Nursing and Allied Health Scholarship and Support Scheme.

In particular, I note their most recent update to parliamentarians on 7 March, in which they said: 'The Allied Health Undergraduate (Entry Level) Scholarship received 504 eligible applications, of which 144 identified as extenuating circumstances. These applicants include people who have experienced either sexual abuse or domestic violence, have a family member with mental health issues or a terminal illness or where both parents have died. SARRAH will only be able to offer five scholarships to these applicants.'

It is concerning that only five scholarships will be offered. The Health Workforce Scholarship Program, which amalgamates six scholarships into one program, was to be ready for the 2017 academic year but has now been again delayed. Those delays are already causing problems for students. For example, the interim funding arrangements for the Nursing and Allied Health Scholarship and Support Scheme have left a cohort of students beginning their studies in 2017 with funding uncertainty for future years. That is no way to try to boost and bolster our rural and remote health professional workforce.

It now also seems that the Taxation Office is considering taxing medical rural bonded scholarships, which would also result in diminishing their value. In response to an Australian Taxation Office discussion paper, the Australian Medical Association notes that scholarships paid to a full-time student at a school, college or university currently are exempt from taxation, subject to specific exemptions and conditions. However, my understanding is that a payment under a scholarship that is not provided principally for education purposes is not exempt. Nonetheless, the MRBS scheme has been treated as having tax-exempt status, with the Department of Health advising: 'MRBS scheme participants are not required to include the scholarship income in their tax return.'

The AMA's response goes on to say:

Current MRBS participants have entered the scheme with the clear understanding that scholarship payments would be tax exempt. This would have been a critical consideration in their decision to accept an MRBS place at university and, if the ATO changes its position on this, then they will have been fundamentally misled and now locked into commitments that they might otherwise have declined. If the ATO is intent on changing its position, then the tax exempt status of existing recipients should be grandfathered as part of any changes.

Having raised these matters, I would therefore ask the minister to clarify what the intention is with respect to the taxation treatment of medical rural bonded scholarships. I suspect that if taxation is going to apply to them in the future then many other scholarships may also begin to be similarly treated.

The bill also makes two other changes aimed at reducing red tape. Firstly, it abolishes the Medical Training Review Panel—the MTRP—which duplicates the functions of the National Medical Training Advisory Network. The National Medical Training Advisory Network was established as a response to the Health workforce 2025 report by Health Workforce Australia. However, it transitioned to the Department of Health when Health Workforce Australia was abolished. National Medical Training Advisory Network members agreed to assume the functions of the MTRP. A national report on medical education and training will continue to be produced each year and be published on the departmental website so stakeholders and other governments will continue to have access to the data.

Finally, the bill also repeals section 19AD, which creates a requirement to conduct reviews of the Medicare provider number legislation. The reviews are limited to sections 19AA, 3GA and 3GC. Notably, section 19AD does not allow the review of section 19AB , which requires overseas trained doctors and foreign graduates of accredited medical schools to practise in a district of workforce shortage for 10 years.

Section 19AA requires doctors to have obtained postgraduate qualifications before they are able to access the Medicare Benefits Scheme. This affects both overseas and Australian trained doctors. Section 19AA was introduced in 1996. At the time, a number of groups in the medical workforce perceived it to be a risk to the future employment opportunities of the doctors in training at the time. As a safeguard, a sunset clause was included so that the parliament would need to approve the continuation of the measures in section 19AA. The sunset clause was removed in 2001 on the recommendation of a mid-term review of the legislation in 1999. It was replaced with section 19AD, which requires reviews every two years. In 2007, that requirement was changed to reviews every five years.

I briefly mentioned sections 3GA and 3GC, which 19AD also requires reviews of. Section 3GA allowed for the creation of a register of approved placements. This provides for the registration of medical practitioners in approved placements, which enables doctors subject to section 19AA to provide professional services while undertaking training towards fellowship. Section 3GC allowed for the creation of the Medical Training Review Panel, which, as I mentioned earlier, is being abolished.

As I said at the outset, this legislation could be improved. Whilst Labor will be supporting it, we will be moving amendments in the Senate. Those amendments will be aimed at improving the legislation by, firstly, broadening the scope of the commissioner's role. The bill states:

If requested by the Minister, the Commissioner may also provide advice to the Minister on matters relating to rural health reform.

I stress the words 'if requested by the minister'. We know that ministers in this place change, so the broadening of the scope of the commissioner is entirely dependent on the minister of the day. Our view is that the commissioner should, in fact, have that broader scope from the outset, and I believe that is what was the health professionals who I have spoken to in the course of the last 12 months or so would expect. This wording—as I stressed a moment ago—which refers to the request by the minister, along with the abolition of the position in such a short time frame, confirms our concerns that the government sees the role of the National Rural Health Commissioner as being to establish the national rural generalist pathway and to do little else. It would seem to me that by the time the commissioner is appointed and proceeds with the establishment of the national rural generalist pathway there may not be a great deal of time or scope for the commissioner to do much else beyond that. It would also seem to me, given that there are a whole range of other matters that have been brought to the attention of members of parliament with respect to what is needed to improve health service delivery in outback Australia, that there would be many other matters that the commissioner could apply himself or herself to, and that the role ought to be much broader than what it appears to be under this legislation. Indeed, from having read several of the papers prepared by the various health organisations, there is a range of other health professionals who, in their own fields, would equally like to see their specific areas addressed as much as those relating to GPs.

The other matter I refer to is reviewing the commissioners role. It would seem to me that the appointment of any position, and this is an important position, would warrant at some point in time a review of that role before it is terminated. I understand the commissioner will be reporting annually to the minister and I would expect that report to be made public. That would be one way of providing some measure of assessment as to how the role is working. But, regardless of that, it is more important to know what impact the commissioner has had on changing health service delivery in outback Australia prior to the termination of the appointment. It may well be that in three year's time the commissioner is halfway through a particular initiative that he or she would like to see completed, and it may warrant an extension of the commissioner's time. Under this legislation, new legislation would then be required to facilitate that.

I also note, and I mentioned this at the beginning of my remarks, that the commissioner is entirely dependent on negotiations with the Department of Health for any staff resources that may or may not be allocated. Again, it would seem to me that this immediately puts the commissioner in an awkward situation where, perhaps, the resources and support staff required are simply not there. In turn, that would limit the ability of the commissioner to perform the role as required and achieve the hoped for outcomes. Those are all matters of concern.

It is also of some concern that the position of commissioner may just be part-time under the act. I do not know if a short list has been drawn up by the minister, if an appointment is imminent or what sort of person is going to be appointed, but I have no doubt that at the time it will be a person who is able to fulfil the requirements specified under the act. But I would hope that it is not a part-time appointment because that would suggest that it is a three-year appointment which is reduced because it is only a part-time appointment.

Lastly, there have been some concerns that, because of the narrow focus that this legislation would appear to point the commissioner towards, there ought to be an advisory body of some sort established to which the commissioner could turn for advice, discuss matters and get firsthand responses about other initiatives that the commissioner might want to pursue. This would be an advisory board—unpaid—of health professionals from a broad cross-section of the various allied health professions who service outback Australia. Again, it would seem to me to be an eminently sensible suggestion. There is nothing to stop the commissioner from consulting the health professional bodies that currently exist, but it is always useful, as I found out only recently, to have them all sitting at a table together so that they can each hear each other's views on matters rather than individually approaching the commissioner—or the minister, for that matter—with their specific point of view. It makes more sense and, given we are suggesting that the advisory body need not be a paid body, it would seem to me that it would be a sensible proposition, which I ask the minister to consider.

Having made our position very clear and raised those concerns, I move the following amendment:

That all the words after "That" be omitted with a view to substituting the following words:

"whilst not declining to give the bill a second reading, the House notes that:

(1) the position of National Rural Health Commissioner terminates on 1 July 2020, and there is no provision in the bill to extend the position;

(2) there are no review provisions of the Commissioner's position within the legislation;

(3) the scope of the Commissioner's role is primarily focussed on the establishment of a National Rural Generalist Pathway and the bill appears to ignore other issues in rural health; and

(4) there is no advisory body proposed to assist the National Rural Health Commissioner with his or her work."

Our amendment makes Labor's position clear with respect to this legislation, and I commend it to the House.

Kevin Hogan (Page, National Party) Share this | Link to this | Hansard source

Is the amendment seconded?

Anne Aly (Cowan, Australian Labor Party) Share this | Link to this | Hansard source

I second the amendment.

Ted O'Brien (Fairfax, Liberal Party) Share this | Link to this | Hansard source

I rise in support of the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017. This bill represents a clear commitment by the coalition government to the health of the country's rural and remote populations. There are three aspects to this bill. Crucially, it establishes a National Rural Health Commissioner—an independent voice and staunch advocate for health services in the regional, rural and remote areas of Australia. The bill also repeals two sections of the Health Insurance Act 1973 to remove redundant and ineffective legislative processes. Together they bring attention and action to vital services in rural Australia. I would like to commend the Assistant Minister for Health and former Minister for Rural Health for his vision and commitment to the wellbeing of these rural and remote communities. It is for this reason that I support the bill. Let me set the scene, if I may, with words I am sure you are familiar with, Mr Deputy Speaker Hogan:

I love a sunburnt country,

A land of sweeping plains,

Of ragged mountain ranges,

Of droughts and flooding rains.

I love her far horizons,

I love her jewel-sea,

Her beauty and her terror—

The wide brown land for me!

Dorothea Mackellar's poem quintessentially sums up much of what we love about Australia. Her words of course refer more to the bush, and it seems around seven million Australians agree with her wholeheartedly. A third of our population live in regional, rural and remote locations. My own electorate of Fairfax, on Queensland's beautiful Sunshine Coast, is a part of regional Australia. Even though we have more pristine white beaches than sweeping plains, we are indeed a sunburnt country with lots of mountains and there are parts of our region that are also rural. Not only is the Sunshine Coast the healthiest place on Earth and the lifestyle capital of Australia but also, like all regional and rural areas, we benefit enormously from a supportive community, high rates of volunteerism and more social capital than our city cousins.

However, it is an unacceptable reality that residents of regional areas—and especially rural and remote communities, of which Fairfax has only a sliver—experience poorer health outcomes, have higher levels of illness and exhibit a higher health need than those who live in cities. Indeed, on average, those who live in the bush do not enjoy the same access to health services and related infrastructure. This is why this bill is so essential. The establishment of a National Rural Health Commissioner is a crucial commitment of the coalition government and the cornerstone of the government's future investment in rural, regional and remote healthcare services. The government has committed $4.4 million to create and support the commissioner, who will provide frank and fearless advice and have the ability to influence the future of our country's rural healthcare policy.

One of the fundamental barriers to an effective rural healthcare system is the distribution of the country's healthcare workforce. It is recognised that the numbers of doctors with specialist and advanced rural experience and training is decreasing. I have first-hand knowledge of this in my own electorate of Fairfax. On the Sunshine Coast our smaller regional towns are fighting for primary healthcare providers. As the minister knows, I have been actively campaigning for assistance to attract a GP to the rural town of Kenilworth, whose 600 residents have been without a permanent GP for nearly two years now. It is also well known that my colleague the member for Fisher and I have been actively working together to try and secure additional medical places through the national review that is currently underway so that Griffith University can establish a medical school in our region. This is important so that some of best and brightest from our region who wish to study medicine can stay in the region while completing their entire degree. It is also important to attract future medicos not just to our region but to other regions and rural areas across Australia. If they can attend a local medical school it is far more likely that they will become interested in living and building a career in regional and rural areas. We can rest assured that the people of the Sunshine Coast are very alive to how important an effective distribution of health care workers is.

I am delighted, therefore, that the National Rural Health Commissioner will be taking responsibility for rural workforce issues. Innovative and sustainable medical practice solutions are exactly what is needed for smaller, harder to reach regional towns. Critical to this is the development of a national rural generalist pathway—a core step towards strengthening the rural medical workforce. A rural generalist pathway is not a new concept. There are varying degrees of support and infrastructure available at a state level, but what is not currently available is a coordinated national approach, and this is the gap that will be filled by this legislation.

It should be noted that the National Rural Health Commissioner will not be a lone ranger; he or she will work closely with those who are best placed to advise on the needs of regional, rural and remote communities—the people who live and work there. It is the rural and remote people themselves who are best placed to understand the issues and to develop and manage the solutions. The commissioner will work directly with these community stakeholders, the health sector, universities, specialist training colleges and across all levels of government to gain the best understanding of the issues and advise the government on how to address them.

It is recognised by the Rural Doctors Association of Australia that there is a

…pressing need for reforms to build a rural medical workforce with the qualifications, skills and experience to deliver a generalist medical service that spans the general practice and hospital setting. Without this workforce, the health outcomes of people living in rural and remote areas will continue to lag behind their urban counterparts.

We do not expect every remote town to have the range of medical and health services of our cities and metro areas, but we do expect access to appropriate, high-quality primary healthcare services for people in regional, rural and remote locations.

The appointment of the commissioner and development of the national rural generalist pathway are means to help achieve that very end. The commissioner will work with the rural health sector and training providers to define what is a rural generalist and to develop options for increased access to training and appropriate remuneration, recognising their extra skills. Rural doctors are different to those in the cities: they need a broader and specialist skill set to bridge the gap in services experienced in the communities they serve. These skills require training; they should be recognised and they should be remunerated accordingly.

These are the types of initiatives needed to bring healthcare professionals out of the cities and into our rural, regional and remote communities. But we are not just talking about GPs and specialist doctor services. The commissioner will be responsible for advising on opportunities to improve rural health careers more broadly. This includes the areas of Indigenous health, nursing, dental health, mental health, midwifery and allied health. There is significant scope to provide a national approach to multidisciplinary healthcare delivery across other healthcare services as well.

The bill also cleans up two sections of the act, which are now redundant. It was identified that the functions of the Medical Training Review Panel were being duplicated by the National Medical Training Advisory Network. Members of the panel themselves recommended it be abolished. This has now been done, and removing the related legislation from the act is the logical next step. The repeal of laws that reviewed the Medicare provider number legislation is also a prudent decision. The current legislation calls for the regular review of the Medicare provider number laws to ensure there are no unintended consequences, or burden, placed on agencies. Three reviews have been conducted with no issues identified. Surely, therefore, there is no need for continued further review. The Medicare provider number legislation is well established and it is working as intended.

Locally-based services play a key role in the sustainability of our regional, rural and remote communities, and healthcare services are a core component of this. The appointment of the National Rural Health Commissioner is an essential element to ensure the future way of life in outback Australia and in rural and regional communities continues. I commend the bill to the House.

Steve Georganas (Hindmarsh, Australian Labor Party) Share this | Link to this | Hansard source

I too rise to speak on the Health Insurance (National Rural Health Commissioner) Amendment Bill and I do so because I feel very strongly, as all of us do on this side, about the adequate provision of health care for all Australians, regardless of where they live. This bill, as we heard, amends the Health Insurance Act 1973 to enable the appointment of a National Rural Health Commissioner. We heard earlier from the member for Makin that Labor will not be opposing this legislation, because we recognise the absolute need to address the problem of attracting and retaining doctors in areas where they are needed. Of course, those areas are the regions and rural areas.

An ABC article in January of this year discussed the possibility of a number of rural and remote communities risk being wiped out unless the shortage of basic medical facilities is addressed. It is only natural that people want services when they are living in a particular area, or if they are contemplating moving to a regional or rural area, and one of those basic services is health. The Rural Doctors Association of Australia president, Ewen McPhee, said that unless there was a renewed focus on the basic needs of smaller rural communities across Australia there would be dire consequences.

I do support the concerns raised by the member for Makin. One of those is that the position of the National Rural Health Commissioner terminates on 1 July 2020. There is absolutely no provision in the bill to extend that position. Another concern is that there are no review provisions of the commissioner's position within the legislation. The scope of the commissioner's role is primarily focused on the establishment of a national rural generalist pathway, and the bill appears to ignore other issues in rural health. Further, there is no advisory body proposed to assist the National Rural Health Commissioner with his or her work.

We know that Australians who live in regional and remote areas are getting sicker more often and waiting longer to see a doctor than their city counterparts. The contrast of this is starkest for those in remote areas, where, for example, average lifespans of women and men are respectively two years and 3.4 years lower than city dwellers. That is a stark difference. Suicide rates, for example, are twice as high in rural and regional areas. Chronic disease levels, including diabetes, coronary heart disease, lung disease, eye diseases and chronic obstructive lung diseases are considerably higher; yet, despite much poorer health, the average yearly Medicare benefits schedule spend per individual in remote areas is $536, compared with $910 in major cities. For Indigenous people the situation is even more dire, with men living two years less in regional areas and seven years less in very remote regions.

I suppose it is the nature of Australia, with its scattered rural and remote populations, that providing essential services to these communities is costly. But it is also absolutely necessary, regardless of the cost. It highlights the dangers of privatising certain aspects of these essential services. This is why we must be vigilant. We know that the ratio of health professionals, particularly in specialised sectors, is much lower in rural Australia than in the city areas. This means that, while the health of Australians is improving in many areas around the nation, there is still a big gap based on where you live. About one in three people living outside the cities and CBD areas reported longer than acceptable waiting times to see a general practitioner. The reasons for these gaps are many.

Personal safety is a high priority issue for rural and remote health workers, as well. This is certainly an area that must be addressed to remove some of the barriers to recruiting more workers to rural areas, especially health workers, GPs and medical professionals. According to the Rural Doctors Association of Australia, incentives to get doctors to move to remote areas are inadequate. The Australian Institute of Health and Welfare's 2008 report, for example, found that the number of medical practitioners was rising, but not in the right places. At the time of the report there were 335 doctors per 100,000 people in the big cities, compared with just 135 in remote Australia. The situation has certainly got worse since this report came out in 2008. Small town doctors often act in several capacities. They need separate skills to those of city doctors. They act as the local GP, the hospital's visiting medical officer and the after-hours responder in many cases. This is a very demanding job.

What has the coalition done to address rural and remote health care availability in the past? The establishment of the National Rural Health Commissioner is certainly a step in the right direction. The question is whether it will be enough to address those inadequacies that exist in rural areas. Importantly, will this compensate for past bad decisions? For example, one of the first health cuts made by this government was abolishing Health Workforce Australia. Abolishing Health Workforce Australia disproportionately impacts directly on the rural and remote health workforce, because that is where the largest imbalances exist.

So let us not forget that this is a government that has failed rural health in multiple ways. Some of those ways where they have failed rural health are through the Medicare benefits schedule freeze, the increases in the cost of medicines, cuts to pathology bulk-billing incentive payments and cuts to health workforce scholarships.

With this in mind, as we heard earlier, the Labor opposition will be moving amendments in the Senate that we believe will make this better legislation and which we ask the government to support. The amendments will be to broaden the scope of the commissioner's role, review rather than cease the commissioner's role on 1 July 2020 and establish an unpaid advisory board to support the commissioner with good, adequate advice. This will go some way to address the shortcomings contained in this particular bill. The commissioner will be appointed by the minister on either a full-time or part-time basis for a period of up to two years, and is only eligible if they have experience in rural health. The commissioner must provide a report each year to the minister for presentation to the parliament about the commissioner's activity, and the commissioner will have a number of tasks, including providing advice to the minister on matters relating to rural health reform upon request, defining what it means to be a rural generalist and developing a national rural generalist pathway. A rural generalist pathway provides postgraduate medical students with training and development to become a rural generalist, although it would be the role of the commissioner to define what it means to be a rural generalist.

The question remains about whether this is slightly superfluous, given that there is already an existing definition based on the Cairns Consensus from the 2014 World Summit on Rural Generalist Medicine. There is no doubt that the commissioner appears to be given a very narrow role. Whilst the development of the national rural generalist pathway is welcome, it is quite unclear that the commissioner will have much more of a role than that. The government had the opportunity to establish a commissioner's office with real political support and clout, which could put rural and remote health on the agenda, bringing those levels back up to the level of what we have in the cities, or close to it.

What does it mean exactly to give the commissioner a life span only until 1 July 2020, without any knowledge of the future after 2020? At that point the commissioner will cease to exist. That is only around three years. It is not really long enough to address these complex problems. I must say that the idea is not really original, either. Labor had already committed to appointing a rural health commissioner in the lead up to the federal election. We also announced that we would establish a health reform commission, whose job it would be to deal with rural and regional health workforce matters.

Now we know, from the reaction to Labor's announcement prior to the elections, that such measures as are contained in this bill would be largely welcomed by the main stakeholders. However, I believe that what stakeholders, practitioners and patients want is a clear commitment to the provision of adequate health care in rural areas. The reason there is a level of insecurity around whether this government actually has the commitment is its track record of turning its back on our universal healthcare system.

When Labor introduced the Medicare system in 1986, it had been met with strong opposition by the coalition from 1983, when the Hawke government first began it. It was only after the coalition's fifth successive defeat, in the 1993 federal election, that John Howard committed the coalition to retaining Medicare because he accepted the reality that the Australian public valued Medicare.

Moves towards privatising elements of health care currently covered by Medicare, as we have seen the coalition government do, are a stealth strategy of incremental cuts to reform Medicare as a safety net for the poor. They have adopted strategies of incremental cuts, by tinkering with Medicare, that are designed to gradually erode the broader public's confidence in, commitment to and support for Medicare. We must stand up and fight these moves, or the tipping point will be reached and Medicare will be recast as merely a welfare program for the poor. I therefore support the amendments that will be moved in respect of this bill in the upper house and urge the House to support them.

Damian Drum (Murray, National Party) Share this | Link to this | Hansard source

It is a great opportunity to be able to stand in this place and talk on the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017. I was in the House last sitting when the Assistant Minister for Health, Dr David Gillespie, got up and read the second reading speech to the House. It was great that we had a situation where someone with an extensive knowledge of the health industry—a gastroenterologist—was able to talk on issues surrounding rural health, and that someone who has spent an enormous amount of time in the rural health sector as a professional is able to then adjudicate over the introduction of this commissioner.

The introduction of the National Rural Health Commissioner was a major platform of the National Party in the last election. It was one that the then minister, Fiona Nash, was able to put front and centre as, more or less, a line in the sand, saying: 'We cannot accept this inequality that exists in rural health and regional health any further. We need to understand that, yes, we might have enough doctors, when you look at the Australian population and divide it by the number of GPs and the number of specialists that we have; however, you would be a fool to suggest that we have all those doctors in the right places. Therefore, what we need to do is have a continual referencing and a continual filtering to make sure that, as we expect, the third of our population who live outside of the major regional cities have a very efficient and very world-class health service.'

We also understand that that is just not the case at the moment. We also understand very clearly that, if you do live in rural and regional—but predominantly rural—Australia, you are going to be in that bracket of people who experience a higher rate of chronic disease than would our metropolitan cousins. We have a shorter life expectancy in rural Victoria and rural Australia. We have higher risk factors of smoking, excessive drinking and obesity. This is often put in place primarily because, in many of the areas we are talking about, we have lower wages and lower incomes. It is becoming more and more apparent now that education has a direct correlation to wealth and that when you map our wealthier and our poorer suburbs you get another direct correlation between wealth and health.

Of those health areas, the first to shine through from having low wealth in the economy, or in the community, is that you find things such as certain types of cancers. You are going to find that areas such as oral health and dental health are some of the first areas that are going to show very, very poor outcomes. And, quite simply, people do not have the money to go and get skin cancers checked. They do not have the money to go and get some ailments that may be threatening and worrying checked. They simply do not have the time or do not have the money to invest in some of the high-priced services that might be available. Certainly the opportunity to get this work done cheaply sometimes does not exist in the regions. Plus, the distance to the services becomes cost prohibitive and becomes time prohibitive. And, quite simply, we know that there are higher rates of preventable cancers, such as melanomas and lung cancers, in regional Australia and rural Australia than there are in metropolitan Australia.

I know that the Deputy Prime Minister and Leader of the National Party has continually said that it is our job in here to make sure that, for those who are doing it tough, we do not make their lives tougher. I think that is something that we just need to understand. This bill is going to, hopefully, create a system where the commissioner will be able to highlight and pinpoint significant gaps in our health system and our health services and will be able to then report those gaps back to the minister to be able to bridge those gaps in our health system.

The former minister, Fiona Nash, who was able to argue for and deliver this policy through the previous election campaign, has labelled this as a bold and historic commitment. I want to commend her for pushing this initiative through. We are going to make sure our rural and remote communities will be able to acknowledge that there is someone who is going to champion and advocate on their behalf to make sure that they get the health services delivered to the locals in their area that they may otherwise be lacking. Going back to where I started, this is because we have that deep line principle that every Australian should have access to a high-quality standard of health care no matter where they live. This first ever National Rural Health Commissioner will be an integral part of the agenda to deliver those more equitable health services.

To establish this role, we are going to have to amend the Health Insurance Act of 1973. This will be a statutory provision enabling the commissioner to carry out their duties independently and transparently. We expect that this position will be totally independent and completely impartial, and the person who fills this position will need to be a fearless champion to carry out the roles within this area. The commissioner will have to do work with the health sector, the universities and the specialist training colleges across all levels of government and will have to champion the cause of rural practice. It would be expected that the commissioner would be someone with extensive experience in the health sector, someone who can consult with a whole range of different players within the health sector and someone who has a real passion for creating some improved outcomes in the future as opposed to what we are putting up with at the moment. This position will roll for two years.

Once appointed, we expect the commissioner to develop a national rural generalist pathway. Again, in sitting down and talking to some GPs last week in my electorate office in Shepparton it became very clear that once someone has completed their medical degree they are about halfway through their training if they wish to become a GP. It is quite shocking when you look at the degree of training and the areas of specialty that we expect our doctors to continue to train in and work towards.

One of the troubles we have in rural Australia is the lack of ability to not just attract but keep many of these health specialist professionals. If we are able to look at ways we could retain the health professionals we are able to attract I think we will be in a much better position. It is also worth acknowledging that in rural Australia our rural generalists tend to have more advanced training than those from a metropolitan centre. We understand that they have a wider set of skills. They obviously have more demand. They work longer hours across a whole range of different incidents and accidents that force them to do work that may be slightly outside their comfort zones. But the sheer nature of life in rural and remote Australia is that if an accident has happened and an injury has occurred then sometimes doctors have no option but to act to the best of their ability.

We also expect that healthcare planning and programs of service delivery must be adapted to meet the widely differing health needs of different communities. Again, one of the areas that I think we can do more work in is strategy and planning. Most regions would have a major regional hospital and, from there—maybe within a drive of 20, 30 or 40 minutes—you would find five or six other smaller hospitals. We need each of those health centres and hospitals to work together in a strategic manner so we do not have duplication of service. The quid pro quo of having duplicated services is that you have total gaps in other services. We need the ability for many of these regions to have healthcare plans put in place to make sure that each of these both larger and smaller hospitals are working hand in glove to ensure that, wherever possible, they are complementing each other and working with each other and not against each other.

There will also be a couple of other amendments to the act in relation to the repealing of section 3GC to abolish the medical training review panel. We understand that in 2014 it was revealed that the Medical Training Review Panel identified a strong overlap between their function and that of the National Medical Training Advisory Network. So repealing the review panel is going to enable this duplication to be cleared up. Also, it will remove the burdensome and ineffective process of the five-year review. It has been more or less acknowledged that these reviews have been ineffective. So, therefore, taking this aspect out of the act will also be a promising and positive initiative.

As I said, we are really looking forward to this commissioner position coming into play. This is going to be an investment of over $4.4 million in rural health to have that real champion who will have the capacity to acknowledge where the gaps are and to acknowledge what is working well. I know some of the PHNs are looking at doing this type of work as well. The health situation we find ourselves in is very, very complex. In many instances it is very frustrating, because so much of the health budget is determined by our states, and so much of the health funding is delivered to the states by the Commonwealth government. And generally what you see when you have more than one body responsible for an outcome, and what you would normally find, is that nobody takes responsibility when things go wrong. This is one of the issues: if we were wanting to start now and get ourselves a well-thought-out process for delivering health services to all Australians, we would not start where we are at the moment. But the fact is, we have got what we have got, and we have to look at the best way forward. This initiative, driven by Fiona Nash and carried on now by Minister Gillespie, is going to see a real champion with the sole objective of making sure that the health needs of rural and remote Australians are well serviced—making sure that, if there are gaps, that those gaps are identified, and that the information about those gaps is then delivered and passed directly through to the Minister for Health, to ensure that appropriate action is taken and that those services can then be best delivered to those people in Australia who most need them. The whole conversation will then revolve around asking questions like whether we have an equitable health system, whether the health needs of people that live in rural and remote Australia are well serviced, and whether we can start closing the gap between the health outcomes of our people in metropolitan Melbourne versus those in regional cities versus those in remote and smaller rural communities.

Ross Hart (Bass, Australian Labor Party) Share this | Link to this | Hansard source

Mr Deputy Speaker, I rise to speak on the bill before the House, the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017, which amends the Health Insurance Act 1973 to establish a national rural health commissioner. The role of the commissioner will be to provide advice to the minister on the role of the rural generalist and to develop a national rural generalist pathway. I acknowledge that attracting and retaining health professionals in the regional and remote areas of Australia is a key factor in improving health outcomes and access to health services in rural communities.

I spend a lot of time in the more regional and rural areas of my electorate of Bass and, unfortunately, these areas experience many of the same health issues that impact regional Australia generally. Australians living in rural and remote areas have much poorer health outcomes than those living in our major cities. According to the Australian Institute of Health and Welfare, Australians in remote areas experience mortality rates that are 1.4 times higher, and suicide rates that are double those experienced by Australians living in major cities. Chronic disease is much more prevalent in rural and regional areas, with rates of asthma, diabetes, cardiovascular disease, cancer and mental health problems all higher than in urban areas. The social determinants of health emphasise that this disadvantage, in all of its forms, flows through to health outcomes. Rural Australians have a higher incidence of risk factors including smoking, being overweight, physical inactivity, alcohol consumption and high blood pressure, compared to their city-dwelling counterparts. Lower levels of health literacy and, often, living in relative social isolation also contribute to the problem. In light of this, it is of particular concern to me that the numbers of health professionals in rural areas, particularly in specialised sectors, are much lower than in metropolitan areas. Indeed, the association between the poorer health status of people in rural areas and the lack of access to health services has been broadly acknowledged in the research. Clearly, there is a need for greater access to health services in regional Australia. There is also much to be done by way of investment in preventative health, as well as in management of chronic conditions after they have been diagnosed. There is also much research to suggest that by combating disadvantage, through education programs and increasing educational attainment across communities, you achieve significant reductions in chronic disease.

The introduction of a specialised rural generalist pathway is a step towards addressing the lack of access to training for doctors in regional communities. This is why, during the last election campaign, Labor announced that we would establish a health reform commission tasked with the challenge of dealing with rural and regional health workforce matters. Labor will not be opposing this legislation. However, whilst we welcome the development of a rural generalist pathway, it remains unclear if the commissioner will have much more of a role than that. In particular, it is a concern that under this legislation the office of the commissioner will cease to exist on 1 July 2020. To this end, Labor will be moving amendments in the Senate which we believe will make for better legislation and which we ask the government to support. These amendments will be aimed at improving the proposed legislation by broadening the scope of the commissioner's role, by reviewing rather than ceasing the commissioner's role on 1 July 2020, and by establishing an unpaid advisory board to support the commissioner. Without these amendments, this is something of a missed opportunity to create a commissioner with real political support and clout who would put rural and remote health on the agenda—that is, on a permanent basis.

The coalition has a rather poor record on rural and remote health. If this government wants to make a genuine difference to the health and wellbeing of rural Australians, in particular of those living in Tasmania, one suggestion I might make is to make a long-term funding commitment to organisations like Rural Alive and Well Tasmania. Rural Alive and Well, or RAW, is a not-for-profit organisation that provides outreach support, information and strategies to rural Tasmanians, with a focus on mental health issues and suicide prevention. I was fortunate to attend the inaugural event held by the Parliamentary Friends of Suicide Prevention, organised by my colleagues the members for Berowra and Eden-Monaro. That event was addressed by an international expert in suicide prevention, David Covington. It was interesting to note that, of the risk factors identified for premature death, a lifetime history of cigarette smoking was identified as risk factor No. 2, with social isolation ranking above that. I spoke in my first speech about the disadvantage within my electorate, and I spoke of the dangers of social isolation and all of the associated health issues that have been identified as flowing from that social isolation. Organisations like RAW are essential to ensuring the ongoing health of our regional communities; particularly in Tasmania, which has the second-highest rate of suicide nationally.

In 2016 RAW worked alongside some 20 regional communities enlisting stronger community participation in local suicide prevention and wellbeing initiatives. This included direct contact with over 2,000 individuals, as well as working with over 250 families across my state. However, RAW will be forced to cut its life-saving outreach services if it fails to secure further government funding. If the government are as committed to the improvement of the health and wellbeing of regional Australians as they claim to be then I would urge them to commit sufficient funding to Rural Alive and Well, and other organisations working in this space nationally, in addition to the steps they now propose under this initiative, to ensure that our rural communities have ongoing access to both the mental and physical health services they need.

We should also not forget that one of the first health cuts made by the coalition was to abolish Health Workforce Australia. HWA was established by Labor in 2009. The premise was a simple one: if Australia was to have the best—and most efficient—health care then health workforce planning needed a coordinated, long-term approach. The abolition of HWA was a particular blow to the regional, rural and remote health workforce because that is where the largest imbalances existed. As will be outlined later in this speech, this is an issue that has dogged government for some years.

I know from my experience as a member of the governing council of Tasmanian health organisation North that regional health organisations, even in a large regional city like Launceston in northern Tasmania, can struggle to provide for renewal of their health workforce. This extends not just to staff within our public health but also to general practice. I know that North experienced difficulties in recruiting and retaining staff—from specialised surgical staff, medical staff, nursing staff and allied health staff right down to the range of support staff necessary to ensure the efficient and effective running of a complex 24-hour, seven day a week operation.

At the other end of the scale, I am aware of the pressures facing general practice in recruiting general practitioners to a regional city. Many GPs complained that they were working long hours and were unable to provide for the succession of their practices as there were no general practitioners willing to work within the city or on its outskirts. These difficulties have been recognised in studies undertaken over many years. The critical nature of medical workforce shortages in rural areas has been identified in reports over the last 30 years.

It was thought at one stage that the medical workforce was in adequate supply; the lack of supply of medical practitioners in rural and remote areas was attributed to maldistribution of the medical workforce. There have been successive attempts to address this issue with a combination of approaches including additional Australian general practice trainees, the use of overseas trained doctors, maximising the workforce participation of existing general practitioners and the introduction of new models of care.

Despite this response, the maldistribution is still occurring. The medical practitioner supply between 2000 and 2004 was found to have risen in metropolitan regions and again demonstrated a shortfall in non-metropolitan regions. The current situation, despite all efforts, still demonstrates a maldistribution between rural and urban areas, although there are some improvements in some areas. It is obvious, therefore, that many rural communities must struggle in the recruiting and retention of basic medical services through the attraction and retention of staff necessary to run a general practice or a local hospital.

Prior to its shutdown in 2014, HWA's efforts delivered an additional 446 nurses and allied health professionals in rural and regional communities. In their submission to the Senate inquiry into the abolition of HWA the National Rural Health Alliance noted that many people in rural and remote Australia have poor access to many types of health professionals and the services they provide. Further, the alliance emphasised that HWA had been investigating the need for integration of education, training placement and hospital training activity for medicine and other health professions with a view to improving access to a range of medical professionals and services for regional communities.

I would note that, since the Turnbull government abolished HWA, there has been a general decline in the number of full-time equivalent general practitioners in remote and regional areas. Nevertheless, this legislation seeks to address this issue with the establishment of a commissioner to provide advice to the relevant minister on the role of the rural generalist general practitioner, to develop a national rural generalist pathway and to provide advice on rural health reform generally.

The role of a rural generalist is to recognise as a matter of policy that medical practitioners in rural and remote areas are required to have a broad range of skills in order to serve their local communities. It is said that today a rural generalist is likely to be a GP who works in community based primary care but also in an acute care setting and has specialist skills in particular areas—typically obstetrics, anaesthetics and/or surgery. Many years ago GPs may have routinely delivered obstetric and/or anaesthetic services and/or minor surgeries, but specialisation has led to a reduction in this and a preference to deliver more specialised services in larger centres. The rural generalist model has been extensively analysed in a systematic review conducted in 2007 and subsequently in a Senate Community Affairs Committee inquiry in 2012. Importantly, there is also an existing model, which is the rural generalist pathway developed by Queensland Health.

There are, no doubt, areas in which specialisation will be the most effective and efficient way to deliver health care. Nevertheless, there are areas in which specialisation is inappropriate, particularly for those who demand access to safe, efficient and effective health care near where they live. However, the adoption of a rural generalist pathway is not without challenges. Whilst it might be argued that a medical practitioner choosing to adopt a pathway as a rural generalist might be treated in the same way as a form of specialisation, there is still some publicly expressed concerns that safety and quality issues may determine that certain procedures are not appropriate for a rural generalist. For example, there are some procedures which are of such complexity that a practitioner is required to demonstrate proficiency through exposure to a sufficient number of procedures over the course of a year.

Specialisation facilitates the concentration of types of work in the hands of those who possess particular skills. There may be concerns as to safety when there are low volumes of procedures to be performed by a particular practitioner, notwithstanding that that person may be otherwise well qualified and experienced in general practice. The review undertaken in 2007 noted that there are other structural barriers to the delivery of generalist services, including the growth of fly-in fly-out specialist services, improved retrieval services, role delineation of hospitals, rising medical indemnity costs and litigious populations. Overall the 2007 review concluded that the generalist model is a practical and cost-effective means of meeting the comprehensive health needs of rural and remote communities, which have lower population densities.

Mark Coulton (Parkes, Deputy-Speaker) Share this | Link to this | Hansard source

Order! The debate is interrupted in accordance with standing order 43. Debate may be resumed in a later hour, and the member for Bass will be given an opportunity at that time to conclude his presentation.