Helen Polley (Tasmania, Australian Labor Party, Shadow Parliamentary Secretary for Aged Care) Share this | Link to this | Hansard source

The Health Insurance Amendment (National Rural Health Commissioner) Bill 2017 amends the Health Insurance Act 1973 to provide for the appointment of the National Rural Health Commissioner as a statutory office holder. The bill sets out the functions of the commissioner, which will be to provide advice in relation to rural health to the minister responsible for rural health, including by (a) defining what it means to be a rural generalist; (b)    developing a national rural generalist pathway; and (c) as requested by the minister, providing advice to the minister on matters relating to rural health reform.

The need for a rural health commissioner has been established but the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017 only goes part of the way to delivering an effective one. Labor supports this legislation but would like to see the government take it further. There are several issues which are obvious from the outset. The commissioner's position will cease on 1 July 2020—in just three years; the appointment itself is only for two years; the position may be a part-time position; the commissioner will be limited in his or her ability to act with full autonomy because they will have to go through the health department for even the most basic of staff requirements; and the role appears to be very narrow in scope.

Why the bill only provides for a commissioner for three years is a mystery. Are all of rural Australia's health needs going to be fixed in that time? Is there some guarantee that no future issues or needs will arise? The Assistant Minister for Health has said that this is 'an incredible and historic occasion'. We believe that the role of the commissioner should be a little more substantial to live up to that description. Stakeholders have advocated and probably expected that the commissioner's position would be a more long-term arrangement that would allow the commissioner to achieve longer term outcomes. The National Rural Health Alliance has welcomed the appointment of a rural health commissioner, in the hope and expectation of a lot of positive changes. The NRHA wants the commissioner to engage with, support and promote policies addressing chronic disease in rural Australia, and to develop key indicators of rural health and report annually on their progress. They sound like long-term objectives. If abolished in 2020, the commissioner will only be able to report three times and will then be gone.

The commissioner's role, as set out in this bill, appears to be very narrow and mainly focused on a national rural generalist pathway. Labor is in full support of the establishment of a national rural generalist pathway; however, the commissioner's role can and should be about more than that. The sobering facts about the health of Australians living in rural areas confirms that they need and deserve quality, consistent health care from doctors and health professionals who are well trained and prepared stay. Many chronic diseases are significantly higher in the country. Suicide rates are double. Dementia rates in rural and remote areas are higher than the national average. With those statistics, it is not surprising that the life span of people in rural Australia is disturbingly shorter than people who live in the cities.

Many of the challenges in rural health directly relate to the health workforce. There is a geographic maldistribution of healthcare professionals in Australia. It is already difficult to get healthcare workers to go to remote areas. Reported cases of sexual assault and physical violence against healthcare providers, both during work hours and even in their own homes, is a major concern for remote health professionals. If we want to attract more people to work in rural and remote areas, we need to improve their safety. The remote workforce, particularly the registered nurses who work in outlying areas is also an ageing workforce. This will mean that, in order just to maintain current levels, recruitment will need to replace those workers when they retire. We need to rebuild confidence in rural and remote healthcare workplaces. A more stable workforce will go some way towards achieving that, but so far the government has done little to promote it.

This is a government which has cut millions from the Health Workforce Scholarship Program and abolished Health Workforce Australia.    Cuts to health workforce scholarships have reduced the number of scholarships being offered. Delays with the Health Workforce Scholarship Program have seen many students commence their studies this year with uncertain funding for future years, and many of these are rural Australia's future healthcare providers.

For all rural people, there has long been an issue with the provision of and access to adequate health services. The remoteness of many locations presents inherent problems that have a direct impact on health outcomes. Greater distances to travel to access or provide services means greater costs to providers and to patients in both time and money compared to people living in cities. Telecommunications, especially a lack of affordable, reliable and fast internet, is a critical issue for most people who might think about moving to a rural or remote area. But a lot more needs to be done to address rural health issues, including ensuring that those rural Australians who cannot afford private health cover do not fall through the cracks. As it is, less than 48 per cent of people in rural and remote regions have private health insurance. This compares with 61 per cent for people living in major cities.

Significantly, people in rural areas are more likely to need the services more readily accessed through private health cover. In the less than four years the coalition has been in office, insurance premiums have risen 23 per cent. I could not believe that: a 23 per cent increase in premiums in less than four years of this government. That gives us some idea of why rural people on low wages cannot afford to maintain their cover. At the same time, the government has frozen the Medicare rebate, increased co-payments, cut $1.4 billion from preventative health and cut bulk-billing incentive payments to pathologists and radiologists. This, of course, affects all Australians, but its impact on rural and remote Australia is where they feel it the most. The national rural generalist pathway will help address some of these issues by providing a greater level of health care in the long run.

I will briefly mention two other aspects of the bill. The bill abolishes the Medical Training Review Panel. Its functions will be absorbed by the National Medical Training Advisory Network, which was established in response to the Health Workforce 2025 report. NMTAN was part of Health Workforce Australia but was moved to the Department of Health when, as I mentioned earlier, the coalition abolished Health Workforce Australia. Each year, a national report on medical education and training will continue to be produced and published on the Department of Health website. This will ensure that stakeholders and state and territory governments continue to have access to this data. The requirement to conduct reviews of the Medicare provider number legislation, section 19AD of the Health Insurance Act, is being removed to reduce the regulatory burden for external stakeholders, such as rural workforce agencies. Since their inception, these sections of the act, section 19AA, 3GA and 3GC, have not changed, despite reviews under sections 19AD in 2002, 2005 and 2010. We consider those last two matters to be fairly uncontroversial and will not oppose them.

The appointment of a national rural health commissioner and the creation of the national rural generalist pathway are positive steps in addressing rural health needs. However, the commissioner could be a much more substantive position; a longer-term position with broader focus has the potential to deliver more for rural Australia. As I have said from the outset, Labor supports this bill. We had foreshadowed our own amendments to address several of the issues with this bill; however, the government has come to the table with their own amendments. Labor appreciates the government's willingness to consider the concerns we have highlighted which were the commissioner's position being abolished without review after only three years; the apparent narrow focus of the role; and, finally, that there was no advisory body to support the commissioner. Broadly, the amendments proposed by the government achieved much of what we were proposing. They are acceptable to us and they do address our main concerns. We, therefore, do not need to move our own amendments. I commend the bill to the Senate.

Richard Di Natale (Victoria, Australian Greens) Share this | Link to this | Hansard source

I rise to speak on the Health Insurance Amendment (National Rural Health Commissioner) Bill 2017. Let me begin by placing on the record the Greens support for the national rural health commissioner. It is a role that will begin to address the entrenched workforce issues in regional and rural medicine by putting in place a national rural generalist pathway. We welcome the government following through on their commitment to establish the role of the commissioner. We note that this work to establish the commissioner and to establish the national rural generalist pathway has been called for by stakeholders for many years; indeed, it was a commitment that the Australian Greens took to the last federal election. It is long past time that we see some real action on the health outcomes in rural and regional Australia, which do lag way behind the health outcomes of people who live in capital cities.

Right throughout regional Australia, and specifically in Aboriginal and Torres Strait Island communities, health care is woefully inadequate. We need a very clear focus on how we turn this around, and the Greens believe that this is a positive step; this new role does mean that we are taking one step in the right direction. It represents a good starting point for the establishment of the commissioner, and we do recognise the broad support for its passage—as I said earlier—of some key stakeholders, particularly the National Rural Health Alliance and the Rural Doctors Association. I want to recognise their strong advocacy and, in particular, their constructive contribution in relation to improvements to this bill.

We are always happy when the government does listen to stakeholders—sadly it does not do it enough—but it is good that on this occasion it has talked to some of the key stakeholders and is now talking to the Senate. In response to that, it has actually made its own amendments to the bill. Ideally, this place would work better if governments of all persuasions sought the views of members of the crossbench and the opposition before they drafted a piece of legislation. It has always struck me as somewhat curious that a government does not do that, that they do not take into account concerns raised by members of the opposition crossbench. Nonetheless, we are still pleased that they have moved amendments—subsequent to the drafting of the bill—which do improve this legislation.

We will support the bill and the government's amendments. But I will also be moving a second reading amendment, to highlight the Green's view that the issues facing health in rural and regional Australia are extremely complex and they have been longstanding, and that, ideally, the commissioner's role should be an ongoing one. The scope of the commissioner should be broadened further, and they should be given the capacity to provide recommendations over time to address all of the myriad issues that are facing rural health practitioners.

The bill basically establishes this National Rural Health Commissioner, who will be responsible for providing advice to the minister on the role of the rural generalist and the training program or pathway for national rural generalists. Of course, thanks to some of the amendments the government has made to their own bill, they will also have the capacity to provide other advice on rural health reform.

As I said earlier, the Greens support the establishment of the national rural generalist pathway as a really clear recognition of the unique, varied, challenging, exciting, daunting role sometimes facing doctors in rural communities. Having been a doctor who has worked in rural communities, I can say it is an extremely exciting and challenging role. It provides you with the opportunity to be confronted with things that your counterparts who are practising in urban environments rarely see.

There are longer hours; often you are on call around the clock. You have got a very broad scope of work, unlike in capital cities, where things that might be outside the scope of what seem traditionally general practice issues are referred on to specialists. If you are a rural generalist, you have got to be a jack of all trades. It takes in general surgery. You are often involved in obstetrics, emergency medicine, anaesthetics and psychiatry. You work across a gamut of specialties and you need to be on top of all of them, so it is a very challenging role.

The bill requires that the commissioner consult with the health sector and training providers to, firstly, define what it means to be a rural generalist. What is it that sets that pathway apart from ordinary general practice? In doing that, it needs to look at remuneration for generalists so that these particular skills that have been developed over time, the circumstances in which they work with limited specialist pathways for referral and all those other things are recognised.

We are also pleased that the government has listened to stakeholders to ensure that, once the commissioner has worked on this, it can look at some broader issues across rural health. We are extremely pleased to see that the minister has committed in his speech that issues relating to nursing, dental health, pharmacy, Indigenous health, mental health, midwifery, occupational therapy, physiotherapy and other allied health issues will also be considered. It is really important to remember that health in whatever context takes place within a multidisciplinary framework. It is well and good to be focusing on the doctors who provide health care, but there are myriad other heath providers who do equally important work, and it is critical that the commissioner is able to consider issues that affect those allied health professionals.

The bill, however, does set the commissioner role to expire on 1 July 2020. I am pleased that the government has listened to stakeholders and, indeed, to the Greens about the need for an extension to the role to be made in good time before that expiry date and for a clear review of the activities of the commissioner to be reported to parliament as well. It is the view of the Greens that if there is still work to do in rural health reform at the time of the expiry then the commissioner's role should be extended. I think there is the very real possibility that this becomes an ongoing role in helping to continue to work through many of the issues that people living in regional communities face.

We are supportive of this bill because it represents finally some concrete action from the government to address the fact that there are huge disparities in health outcomes between people living in rural and regional areas and those living in metropolitan areas. There is a big gap here, and it is significant. It has been there for a long time, and for too long governments have ignored it. We have heard from the Australian Institute of Health and Welfare, which time and again has detailed this huge disparity. They have reported that Australians in remote and very remote areas have mortality rates 1.4 times higher than those living in major cities. That is a significant gap. If you look at something like coronary heart disease, it is somewhere between 1.2 and 1.5 times higher in rural and remote areas. Death rates from diabetes are even worse: between 2½ and four times higher.

Of course, we know that that is linked to disadvantage as well. Many people in rural areas live in areas of high economic disadvantage, but we have a responsibility to do something about the big health gap that exists. We see the rates of many chronic diseases like diabetes, cardiovascular disease, airway disease, asthma, cancer and, of course, mental illness and suicide as significantly higher for people living in regional and rural areas. As I said earlier, because of that variable high socioeconomic disadvantage, we know it is associated with a whole range of risk factors: things like smoking, being overweight or obese, physical inactivity, alcohol consumption et cetera.

Of course, for many of the rates of illnesses that I have described, the lower life expectancy, the higher rates of chronic disease et cetera, we know that, apart from the divide between metropolitan and rural and remote, there is also a much greater divide when you focus on whether someone has an Aboriginal and Torres Strait Islander background.

We should never ignore the fact that in Australia your postcode determines your health status, and we have to change that. It is clear that we need a concerted effort to focus on and invest in clear actions to start to turn these health outcomes around.

One of the key drivers of poor health indicators are the barriers people face to accessing high-quality health services. One of the reasons for that is the shortage of appropriately qualified doctors. That is why this government's commitment to the commissioner and, indeed, the National Rural Generalist Pathway are so important. It finally begins to recognise that the skills these people have should be recognised, and in doing so we should be able to attract more doctors into this rewarding and challenging area of work.

There are so many other issues. It is not just providing people with access to health care. If you look at my first speech, for example, I made it really clear that one of the reasons that brought me into politics was to impact on people's health. It is not just about having a good health system. It is looking at what the social determinants are—access to employment, education and so on. What are those things that contribute to poor health? We know that, when it comes to rural health, there are a number of things that contribute to that disparity. I mentioned some of those risk factors earlier. Yes, it is a lack of services, but it is also a lack of infrastructure, including IT infrastructure. It is isolation. It is not having access to fresh foods. It is all of those things that compound the problem.

There have also been a range of government interventions in recent years which have had a negative impact on access to health care for many people in regional communities, such as the government's freeze on the Medicare Benefits Schedule, which was instigated, it must be said, by the Labor Party, but was continued by this government—indeed, accelerated by this government. It has had a real impact. Over the last 12 months I have spoken to many, many GPs, who say that it has had an impact and that they are struggling to keep their doors open. In country towns across Australia, GP clinics have been put into a very, very difficult position. We do welcome the fact that at least the government is now considering reversing the freeze, and we hope the government will eventually make the right decision.

Then, you add the cuts to dental health. The government wanted to cut to the child dental benefits scheme, and, ultimately, gutted the funding to public dental clinics. Often, in some of the regional areas, the only place you can see a dentist is by going to a public dental clinic. So these cuts have real impacts. We know that, when you cut access to dental care, you do not just impact on somebody's oral health; it can have serious complications for other conditions, like heart disease and stroke.

We have seen the government rip money out of prevention programs and fail to invest in appropriate drug and alcohol treatment services. They have not put a single dollar towards the implementation of the National Aboriginal and Torres Strait Islander Health Plan. You have to start recognising that health is an investment. If you do not make that investment it will have ramifications across the system as a whole. Our view is that the health commissioner should be looking not just at workforce issues but also more generally at issues which are leading to poorer health outcomes across Australia.

The Greens are supportive of this legislation. We will support the passage of this bill, but we do restate our commitment to the commissioner having to take a broader look at rural health. The minister called the commissioner a 'champion for rural health' in his second reading speech, and I do look forward to his or her appointment and hope they are genuinely given the opportunity to make inroads on the issues affecting health care in regional Australia. Therefore, while supporting the bill, I move the Greens amendment on sheet 8123:

At the end of the motion, add:

", but the Senate:

(1) laments that health outcomes in rural and regional Australia continue to lag significantly behind the rest of the country, particularly for Aboriginal and Torres Strait Islander people and recognises that the establishment of a Rural Health Commissioner represents an opportunity to examine and address the significant work force issues which contribute to this, as well as the range of other causes; and

(2) calls for the Commissioner to be free to examine and make recommendations relating to all areas of policy reform and funding that are relevant to urgently address this issue"."

Thanks very much.

John Williams (NSW, National Party) Share this | Link to this | Hansard source

I am just going to say that I realise time is against us, with the adjournment, but I look forward to speaking on this bill. It is something I am very interested in. This is a really important issue about the National Rural Health Commissioner being established. It will do a lot of good over time. No doubt I will contribute more tomorrow when this bill comes up—if it is on the agenda in the morning.

Debate interrupted.