Tony Zappia (Makin, Australian Labor Party, Shadow Parliamentary Secretary for Manufacturing) Share 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.

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