Stirling Griff (SA, Centre Alliance) Share this | Link to this | Hansard source

The Health Insurance Legislation Amendment (Transparent Patient Outcomes) Bill 2021 will improve health outcomes: the outcome of surgery, and, most importantly, the outcome for the patient. For the very first time, patients who are facing surgery will be able to make an informed choice about their practitioner and their hospital rather than flying blind by accepting without question the surgeon and the hospital selected by their GP. This bill does this by allowing the health minister to create public-facing databases that will detail the performance record of individual surgeons. These databases will also detail the surgical outcomes of the hospitals and clinics in which surgery occurs.

Too regularly, we hear horror stories of patients who are scarred for life and left in agony; of patients who have had to undergo numerous corrective surgeries, otherwise known as 'revisions', and whose lives are forever impacted by the careless knife of a cocky or inexperienced surgeon.

As many in this place would know, the slow-moving regulator often seems close to useless in this space. You only have look at the most recent media story of surgical incompetence to see this—that of cosmetic surgeon Daniel Lanzer, who has reportedly agreed to stop practising in Australia after a joint Four Corners and Fairfax investigation. It took the media to uncover his appalling practices and put an end to him. Where was the regulator, the medical board, the college? How did valid patient complaints not result in the outcome that one media investigation did? This is not an unfamiliar story. We've all read harrowing stories of patients who've undergone a botched procedure and then found themselves in a traumatic battle with the hospital, their surgeon and the system in their often hopeless attempt to get answers and ensure that others don't suffer the exact same fate.

Consumers need more power in their hands to make informed decisions, and that is the sole reason I am proposing this bill. This bill will empower the health minister to make rules to create and maintain a transparent patient outcomes register for a range of medical specialties. Each register will be a public-facing database that will give patients information on the number and types of procedures performed by each surgeon, their surgical revision rates, their mortality rates, their patient demographics, the type and class of prosthesis used if that is relevant, and perhaps even their fees. It is intended that these registers would also detail the performance standards of each facility and for each surgical specialty, because where the surgery happens also influences surgical outcomes.

This bill will also require the minister to consult with the Information Commissioner to ensure that the rules don't breach any privacy rules. Ultimately the information included on these registers would be determined by the minister, but the aim is to include the relevant information for each specialty that would allow patients to make an informed choice about the skill of their prospective practitioner and the standards of each particular facility. The rules in this bill are not prescriptive. The bill gives the minister flexibility about how a transparent patient outcome register would deal with newly minted surgeons who are still building up their bank of experience and how to deal with complaints about incorrect information. This bill is not about creating 'gotcha' databases that undermine professionals. It will ensure that registers are not used in unintended ways and it specifies that information collected for or held on the registries cannot be used in criminal proceedings.

Even so, I know many of the medical colleges won't support it at all. They like to have a closed shop. We found that recently with the IVF industry, but I'll talk a little bit more about that later. They will claim that the bill will create perverse incentives and penalise average performers. I absolutely disagree. Patients want to know whether their surgeon is competent. High fees are no guarantee of this. Neither are framed certificates on a surgeon's wall or the letters after his or her name. Results speak for themselves. Where there is transparency there is always improvement—every single time. Bringing this performance information into the light will ensure that surgeons persist with their ongoing education and keep their skills up to date. It will likely root out complacency and may even help ensure that those who charge the highest fees do in fact earn them. The successful collaboration and launch of the YourIVFSuccess website earlier this year demonstrated the value of and public interest in public disclosure of surgical performance outcomes. That first step improved medical transparency significantly, and it should be the model for all surgical specialties. The process of building such databases does not need to be complicated. I know that this data already exists for some specialties. For instance, orthopaedics has absolutely outstanding data going back well over 20 years.

The Australian Orthopaedic Association National Joint Replacement Registry contains information on all hip, knee, shoulder, elbow, wrist, ankle and spinal disc replacement surgery performed in public and private hospitals throughout Australia. It also collects what they call 'patient reported outcome measures' pre and post surgery regarding pain and surgery outcomes. This data exists. It is shared with surgeons but not the public. Individual performance data is available for each surgeon to view to see how their performance tracks against unidentified peers. They can see whether they plot above or below their fellow orthopaedic surgeons and how many of them are in the low or high ranges. Wouldn't that be valuable information if you were about to undergo a hip replacement or a knee replacement?

This database has existed since 2002. One intention of this disclosure and ranking process and one of the great benefits is that it encourages poor performers to lift their game. The registry shows that a few surgeons continue to use poorly performing prostheses. It also shows a small but significant number of surgeons perform well below expected standards, with much higher revision or repeat operation rates for joint replacement than their peers. Currently, the public only get a small window to see the wealth of orthopaedic surgery data and have no idea whether their surgeon—the surgeon that they are seeing—is a good or poor performer.

Orthopaedic surgeons perform a significant proportion of all surgeries. This means they affect a significant proportion of patients. In fact, 15 per cent of all hospital admissions in 2017-18 were for orthopaedic surgery, including knee and hip replacements—a massive number.

Given the life impacts of poor prosthesis and surgical revisions, I would argue that these thousands of people in households who have been orthopaedic patients should be able to get objective performance data about their surgeon before they go under the knife. Every patient who undergoes any invasive surgery should have this information available to them. It's their money and their health at stake. They shouldn't just have to rely on the reassurances of their surgeon or referring GP that everything will be fine.

This is a bill for consumers. It's not a bill to protect people that are not doing the right thing, that are not up to scratch. It is a bill for consumers, who are often sidelined or feel ignored when things go wrong as surgeries sometimes do. The transparent patient outcomes register, created through this bill, can alleviate some of this needless suffering by helping guide patients before they set off down a road that they may well regret. The databases could also serve to reassure an anxious patient. Those considering surgery will be able to look up the performance record of their intended surgeon and know whether their doctor is well versed in their particular operation or just a dabbler.

Research shows that surgeons who perform fewer surgeries of particular types compared to their peers have increased revision rates—which, again, are repeat operations to go back in to likely fix a problem—and they have poorer patient outcomes overall. A 2014 study that looked at complications arising from hip replacement surgery found that patients whose surgeons had performed 35 or fewer hip surgeries in the previous year had an increased risk of dislocation and early revision. If you are about to have a hip operation, wouldn't you want to know whether your surgeon of choice represented a greater or lower risk? I would; I think everyone here would, but currently that information is unavailable to you.

The bill also deals with an administrative hurdle that would otherwise require data from a minority of specialties, including orthopaedic surgery, to be collected twice from hospitals. The Orthopaedic Association National Joint Replacement Registry is deemed a quality assurance activity under the Health Insurance Act 1973. Identifying data collected for the purpose of a quality assurance activity currently cannot be disclosed to another person or a court without consent, at the risk of serious penalty.

The intention behind the provisions in the act is to provide protection from civil liberty claims. This bill seeks to retain this protection by doing two things: first, it will prohibit data collected for or held on a transparent patient outcomes register from being used in court; second, it creates an exemption for disclosure of quality assurance activity data if it is in accordance with the rules set by the minister. The bill intentionally prevents data collected for or held on a transparent patient outcomes register from being used in unintended ways that cannot be supported by health facilities and practitioners, such as to sue surgeons or to bring criminal proceedings against them. That is not what this is about.

As I say stated previously, the intention of this bill is to provide objective and useful performance data that will help patients make an informed choice about their doctor and hospital before they proceed to surgery. If patients have a clearer view of their surgeon's performance and revision rates, it will help them steer clear of surgeons who aren't experienced in their procedure or who have higher than average revision or repeat operation rates. Without doubt, it would mean fewer complications and surgical trauma for the patient. That is a most worthy outcome.

In an environment where we can't rely always on the regulator, the colleges and the hospitals to rally around patients, we should help them help themselves. This is a most important bill—a very important bill to me—and I hope all senators here will support it.

Wendy Askew (Tasmania, Liberal Party) Share this | Link to this | Hansard source

I rise today to speak on the Health Insurance Legislation Amendment (Transparent Patient Outcomes) Bill 2021, which was introduced to the Senate by Senator Griff on 23 November 2021. As chair of the Senate Community Affairs Legislation Committee I wish to make a brief contribution to the debate. I also wish to acknowledge Senator Griff's interest in, and active participation and involvement in, a number of inquiries undertaken by this committee.

Senator Griff has a particular interest in the transparency of outcomes, as evidenced by another of his bills, the Aged Care Legislation Amendment (Financial Transparency) Bill 2020, which is also before the Senate, as well as his ongoing influential and determined support for transparency in relation to IVF clinics that saw the launch of the YourIVFSuccess website this year. This website, together with a searchable database that provides comparable fertility clinic success rates across Australia, was developed in association with UNSW Sydney. The development of this informative and interactive site was funded through a Medical Research Future Fund grant provided by the Australian government and is a testament to the outcomes that can be achieved through collaboration.

The IVFSuccess estimator allows people to make informed choices about their conception options. It draws on the experience of over 600,000 IVF cycles, performed in clinics across Australia, to formulate an individualised estimate of IVF success for patients. This informs the discussion between the patient and clinicians. What a great outcome, and thank you, Senator Griff, for your determination to see it eventuate. I have many friends who have been through the IVF program and this valuable tool would certainly have assisted them at that time.

I note that in a speech to this place, around the time of the launch for the IVF website, Senator Griff foreshadowed the tabling of the bill before us today. He stated:

It is my hope that one day we will have similar performance transparency for all specialists performing all surgeries in both public and private hospitals. Transparency and accountability are key to improving health outcomes for all of us. They also mean that outliers have nowhere to hide and must lift their game, all to the benefit of patients and to the benefit of the health system.

Senator Griff believes that public disclosure of any surgical performance outcomes, including such areas as gynaecological, cardiothoracic, orthopaedic, plastic and reconstructive surgeries, would be relevant to the proposed transparency of outcome and provide consumers with greater control in determining their surgical provider.

As outlined in Senator Griff's second reading speech, this bill would enable the minister to make rules to create a transparent patient outcomes register that would include information such as the number and type of surgical procedures performed by a practitioner, their surgical revision rate, their patient mortality rate, any prosthesis device they may use, patient data and any other information deemed relevant to that specialty. When reading Senator Griff's speech, I noted that he focused on joint replacement surgery as one example of where a patient may wish to select an orthopaedic surgeon who has undertaken a significantly higher proportion of surgeries than others. As a consumer in this space, it is something I can definitely relate to, and I note that I relied on considered advice from my medical practitioner, personal investigation and research, and third-party references to determine the surgeon that I proposed to use for my knee replacement.

As outlined by Senator Griff earlier, although data in relation to orthopaedic surgeon performance and patient outcomes is collected by the Australian Orthopaedic Association National Joint Replacement Registry, which is funded by the health department, the information held by the register is not available for use for any other purpose; it's simply a quality assurance activity as required by the act. Senator Griff's bill seeks to access this data and allow the reuse of relevant data that is already being collected to be provided for the purpose of a transparent patient outcomes register. The explanatory memorandum provided by Senator Griff details how the transparent patient outcomes bill will preserve the current protections afforded to this information.

The explanatory memorandum also includes details on how the bill seeks to provide protection from liability for secondary disclosure of quality assurance data which is collected for or contained on a transparent patient outcomes register. Orthopaedic surgery is one example; however, as mentioned earlier, there are many others where shining the light on surgical outcomes may assist consumers as they make decisions about potential surgeries.

Cosmetic and plastic surgery has been highlighted over recent months through a number of media stories, including Todd Sampson's documentary Mirror Mirror. Examples of unaccepted outcomes from surgery performed by inexperienced and often barely qualified health professionals in that field have been highlighted. Interestingly, this phenomena has come to light during the Senate Community Affairs References Committee's inquiry into the administration of registration and notifications by the Australian Health Practitioner Regulation Agency and related entities under the Health Practitioner Regulation National Law. This inquiry is continuing and will report in the new year. However, from evidence received already, it is quite possible that access to more transparent and accountable patient outcomes may have enabled different decisions to have been made by those who have approached the committee with their concerns as well.

As those in this place would be aware, the Australian government is working with states and territories under the 2020-25 national health reform agreement, the NHRA, to improve access to timely, fit-for-purpose information, which is needed to make informed decisions about health care. All levels of government are working with the health sector to better understand and remove systemic barriers to improving health care and outcomes, and under the NHRA progress is being made. The national health reform agreement long-term reforms road map was endorsed by all Australian health ministers at the health ministers meeting on 17 September this year.

Providing flexibility to achieving the outcomes is a key component of the road map. Allowing jurisdictions to respond to changing circumstances, they will have the flexibility to identify priority reforms and determine the scope and timing of activities to best suit local needs and support local health system diversity, readiness and funder and provider capabilities. The road map includes an extensive plan for each reform area, including a vision statement, aim, case for change, links to other reforms, intended outcomes, key concepts and COVID-related developments. The road map identifies actions, deliverables and time frames for the following key areas of reform: nationally cohesive health technology assessment; paying for value and outcomes; joint planning and funding at a local level; empowering people through health literacy, prevention and wellbeing; enhanced health data; and interfaces between health, disability and aged-care systems.

One of the key components contained in the road map, enhanced health data, clearly aligns with the intent of Senator Griff's bill, subject to access being made available to the specified data. The rationale for the enhancement of health data, as explained in the document, states this reform supports Australia's governments in their commitment to realise the value of public health data through greater data sharing and information access to transform health care, drive efficiency and safety, create productivity gains and allow better decision-making.

It will ensure that relevant, robust and timely data is available to the appropriate people, to support shared patient-clinician decision-making, improved service delivery, evidence-informed policy development, research and analytics, and system planning. Maintaining data security and preserving individuals' privacy will be central to the reforms.

By expanding public reporting on the quality, safety and value of health services, it is possible that we will see improvements in the health system and improved accountability for outcomes. The NHRA work will build on the Australian Health Performance Framework and existing hospital-level reporting by the Australian Institute of Health and Welfare on information such as emergency department performance, elective surgery waiting times and healthcare associated infections.

The long-term health reforms under the NHRA are intended to provide better coordinated care in the community, to focus on prevention and keeping people healthier longer, and to reduce pressure on hospitals. These systemic reforms will also help improve the experiences of people using services across the health, aged-care, disability and mental health sectors. The stated intent overall is that the long-term reforms will make it easier for people to manage their health.

I understand that the Minister for Health, the Hon. Greg Hunt, has undertaken to consult further with key stakeholders in relation to Senator Griff's bill and is anticipating that a report will be provided to him early in the new year. The findings of the report will be discussed with Senator Griff and other interested parties at that time as we look to provide more information to the Australian public in support of their healthcare decisions of the future.

Kimberley Kitching (Victoria, Australian Labor Party, Deputy Manager of Opposition Business in the Senate) Share this | Link to this | Hansard source

CHING () (): I rise to speak on the Health Insurance Legislation Amendment (Transparent Patient Outcomes) Bill 2021. Labor supports the goals of this bill. We welcome this debate and we thank Senator Griff for the forethought, the care and the compassion that has gone into this bill.

Labor thinks there's a good philosophical point in what Senator Griff has proposed. It's hard to overestimate the importance of the ability of people to make informed decisions about their own lives. This applies to the goods they may buy, how they spend their time and their decisions about health care. Senator Griff's bill is driven by an understandable idea that people make better decisions when they have more information about the decisions they are making. I would add to that that we don't want to be patronising or patriarchal about how people spend their lives and what decisions they make. Importantly, if we consider that having good health is one of the most important aspects of our lives, this bill goes to enable people to make decisions around their health. That is very important. So we thank Senator Griff.

This has been a long-term philosophical aspect of democracy. In the century before the birth of Jesus Christ, Cicero, the great Roman statesman, lawyer and console—I'm reading The Republic at the moment—said:

The safety of the people shall be the highest law.

Thomas Jefferson followed on from that thought and said:

The care of human life and happiness, and not their destruction, is the first and only object of good government.

In light of that philosophical line of reasoning, this bill enables Australians to go to a health system that will support them in ways whereby they are comfortable with the decisions they can make about their health care. There's a view that successful leaders, true leaders, understand that true power comes from not exercising control but from empowering others, and that's what this bill seeks to do. It seeks to empower all of us to have the requisite information to make decisions about our own health care.

Whether you go through the public system, the private system or, as a lot of people do, a combination of both, what we're really asking is: should people have to rely on the good luck of having a GP who is a good diagnostician or who has an excellent rolodex with specialists' names in it? Really, that shouldn't be the measure of whether you have good health care. When you're going to see a specialist, whether it's a surgeon, an obstetrician-gynaecologist or a cardiologist, you want to be able to make that decision yourself. There would be some people who might be more comfortable with a doctor of a particular gender for some issues. This bill enables the minister for health to establish public databases of surgical procedures and patient outcomes. The intent is that people considering a particular surgical procedure will be able to make a more informed choice about their health care and, in particular, their healthcare provider.

Currently, there's little information in the public domain that allows patients to assess the performance, skills and outcomes of individual facilities as well as practitioners. This bill amends the Health Insurance Act 1973 to enable the minister to make rules to establish and maintain transparent patient outcomes registers. These registers may contain data such as the number and types of surgical procedures performed at a facility, the number and types of procedures performed by a practitioner, surgical revision rates and patient mortality rates, any prosthesis device used, patient demographics, or any other information set out in the rules by the minister. The provisions of the transparent patient outcomes bill can be applied to any medical specialty, and that's one of the beauties of it. It is not just related to one particular specialty—it can be used across the board.

Many factors determine the overall success of a surgery, including a patient's age, health and individual diagnosis, as well as their behaviour and willingness to following the doctor's orders post surgery. The bill recognises these facts and allows the minister to ensure they are accounted for so as not to provide the false impression that outcomes are always solely tied to practitioners' skills or decisions, nor to facility characteristics. But no-one can deny that a surgeon's skill and familiarity with a particular procedure is also a key determinant of outcomes. It is a key determinant that this bill aims to make transparent.

While the bill attempts to provide for information indicating a practitioner's skill to be made available on transparent patient outcomes registers, we should acknowledge that, in reality, we can measure relative practitioner skill only indirectly through outcomes. Of course, to be effective, a transparent patient outcomes register resulting from the provisions of this bill will allow for the identification of individual practitioners. It will not require practitioner-related information to be deidentified or provided anonymously. The intent being to inform patient choices, anonymous information is seen as far less useful and not consistent with the objective of the bill. To be effective, the transparent patient outcomes registers must also contain some degree of patient data. This raises questions of patient privacy, which is acknowledged by the bill. The proposed subsection 124ZCB(6) stipulates that the rules must prohibit the publication of sensitive information, including identifying health information about an individual. There's balance in this bill.

Recognising that there is a limit to what patient data can and should be provided through outcomes registers due to legitimate privacy considerations, we must also acknowledge that such limits have implications for the usefulness of outcomes data in registers to inform potential patients. The information to be provided in the transparent patient outcomes register is not intended to be prescriptive or exhaustive. The minister will have broad discretion in deciding what information is to be made public through the register. However, it is intended that the minimum information included in any such rules will allow consumers or patients to make useful comparisons and judgements about a surgeon's experience and capabilities. To do otherwise would defeat the intent and utility of a transparent patient outcomes register. However, Labor acknowledges that there's a danger in this approach, and the possibility of unintended consequences.

As I mentioned above, numerous factors play a role in the final outcomes related to medical procedures, including surgeries. If not designed carefully by the minister, the transparent patient outcomes register could have the opposite effect of its intention. Take, for example, the case of an exceptionally highly skilled surgeon who, as a result of his or her skills, tends to attract the most difficult surgeries in a given specialty and a given location. You could imagine this could skew data. Maybe this is represented by patients who have challenging comorbidities, or maybe it is represented by the needs for a particularly difficult technique employed more frequently in these cases than in others—the point being that, when measuring aggregate outcomes, by definition we lose specific information that could be relevant in making a comprehensive and objective assessment of performance and skill. This is true, of course, in any field of endeavour and is no less true in surgery.

A simple accounting for average patient outcomes by practitioner could represent this surgeon as performing worse than his or her peers when, in reality, the opposite is the case. Maybe that's the surgeon you actually want for a difficult procedure. This would not only represent a personal and professional injustice with respect to our hypothetical surgeon; it would represent a danger to patients, as patients unaware of the deeper issues at play could base decisions on simplistic, aggregate and only partially informed data. I do not know whether it's possible to collect and include all the relevant data that would be needed to guard against such unintended consequences in the context of this bill. That is an open question that Labor would like to hear the views of experts on. Even if it is the case that all data could be collected without breaching patient privacy protections, there is no assurance that the minister would require its collection and publication on transparent patient outcomes registers.

This bill represents a good-faith effort to improve patient choice and patient outcomes. It also represents a key strain in a democratic system: to inform people and to give people the right to make good decisions for themselves. Labor supports these goals, as should anyone who is interested in the welfare of all Australians. I again thank Senator Griff, and we welcome this debate.

Andrew McLachlan (SA, Liberal Party) Share this | Link to this | Hansard source

I rise to speak on the Health Insurance Legislation Amendment (Transparent Patient Outcomes) Bill 2021. The bill, if it finds favour with the Senate, will allow the Minister for Health to establish public databases of surgical procedures and patient outcomes, to allow consumers who are considering a particular procedure to make an informed choice about their practitioner. The mover of the bill, my South Australian colleague Senator Griff, argues in debate that such information in the public domain will allow Australian patients to objectively assess skills and outcomes of individual practitioners and that the bill will repair a lack of transparency that currently exists in what I suppose I could describe as the consumer market for medical services.

The bill technically seeks to amend the Health Insurance Act 1973 to enable the minister to make rules to establish and maintain a transparent patient outcomes register or registers, as the case may be, that contain data such as the number and type of surgical procedures performed at a facility, the number and type of procedures performed by a practitioner, surgical revision rates and patient mortality rates for each facility and practitioner, as well as any prosthesis device used, patient demographics or any other information set out in the rules by the minister. The bill, in effect, gives the minister wide discretion to effectively construct or structure the nature of the register or registers. Registers can be for particular surgical interventions and can also relate to particular medical professions, so there is a degree of flexibility and empowerment of the minister to do so. As we've heard from Senator Askew, the government's intention through its Minister for Health is to consult widely in relation to this bill and to share those findings with the mover of the bill to see the best way forward or whether this bill may require further refinement.

This bill raises two interesting issues. First, around privacy, which the bill takes great pains to protect and, second—and this was touched upon by Senator Kitching—the nature of the presentation of that data, which we hope will empower the consumer and not confuse the consumer. I'm also interested in, in relation to this bill, how that will impact on the performance of the medical profession as a profession—that is, the interplay between the delivery of information and how the profession, both as individuals in the profession and the profession as a whole, will respond—we hope positively—if this bill is passed.

On the issue of privacy, Hippocrates, the Ancient Greek physician, pledged to keep information about patients private and confidential, so this is not a new concept. In fact, the Hippocratic oath states:

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself …

So it is not a new concept, and it is one which we've grappled with in the past. This bill aims to keep the balance—that is, to collect the data for the societal benefit whilst protecting the individual. But, to gather the data, it has to be protected; otherwise, it will be used for a variety of other purposes, which could prevent its ultimate collection or affect the ability to rely on that data and undermine its validity. This is an old trade-off which has occurred in health, and the trade-off is being extended to allow the creation of these registers. Senator Griff stated in his second reading speech:

The bill endeavours to strike a balance between providing useful information to guide patients, providing ongoing protections to those who, in good faith, provide, collect and manage performance and outcomes data, and also endeavours to ensure registry information is not appropriated in unintended ways, such as for court proceedings.

As I've said, this is not a new concept. Protections of personal privacy are always used to protect the interests of individuals, while the primary justification for collecting personally identifiable health information for health research is for the benefit of society. It's an old balance and one which I think is maintained in the bill.

In preparing for the debate today, I would like to thank Senator Griff for including in the explanatory memorandum to the bill a statement of compatibility with human rights, which I found informative and which also alleviated potential concerns that I or others may have had in relation to privacy. The conclusion to that statement says:

This Bill aims to assist individuals to access information about a healthcare provider and exercise informed choice before proceeding with surgery, and so is compatible with human rights as it promotes the right to a high standard of health, the right to control one's health and the right to information accessibility.

From my own perspective, I do not find fault with those assertions, and I have considered the arguments of the mover carefully.

What has particularly interested me about the issues raised by this bill is their interplay with the profession. Historically, we have relied on the medical profession to self-regulate. In effect, we have placed our trust in the medical profession and the doctors and surgeons within it, and we have not sought to question their counsel or their wisdom.

Society has moved on apace. Individuals in our community want to have a dialogue with their doctors and specialists, and in that dialogue they want to be informed. That is why the seed of this bill has great attraction, because it empowers the consumer to have a dialogue with their medical professional—not necessarily on equal terms, because in a doctor-patient relationship there is a lack of power: one has great knowledge, and one is ill and concerned for recovery. So, the relationship has never been equal, which is why the profession was created—to create some balance and self-responsibility on those providing the care.

When discussing professions I always come back to an Australian Bar Gazette article, a reprint of part of a presidential address delivered by Mr Hilton to the English Law Society titled 'The nature of a profession.' He says that one of the really attractive arguments about professions—he's referring to both the medical and the legal profession, the latter of which I'm a member—is that before a group of individuals can be called a profession they must follow their trade or craft in the spirit of public service. That doesn't rule out the need for fair reward. The point is that the first priority is to apply all the person's knowledge, energy and abilities in doing the job, and earning a reward is incidental to that, But, as the mover of the bill has indicated, that is not always the case—in any profession—and there have been considerable failings in the medical profession to clean up its own dirty linen, might I say.

Senator Kitching also indicated that there may be different behaviours as a result of the data. For example, because it's aggregated, it may result in a debate with a patient who is not necessarily as informed. I don't really want to speak for the mover, but as I understand his contribution here, he wants an empowerment conversation. That does not necessarily mean that this data will inform the patient to the nth degree, because they are not data experts. But it will allow them to come to the surgeon's desk or the doctor's surgery and say: 'This is the public data. Please explain to me why you think this surgeon is the best.' I think that's the attractiveness of this legislation, because no legislation like this can generate perfection.

One of the interesting things—and I don't profess to have a crystal ball in relation to this—is how the profession will respond. It could be that the less-noble members of the profession—those who do not put societal benefit as one of their primary drivers in the profession; remuneration is higher to them—might reduce their scope of practice and operate only on those they think are going to have a greater chance of recovery. One would like not to think so. My point in raising the interplay with the profession is that the profession will have to do more work on this to ensure that their members do not respond in a base way to this sort of data being held by the patient.

It will also, I think, have positive knock-on effects for the procurement process, particularly with prosthetics. We know that there are very hard sales techniques around prosthetics, and the patient needs to know whether they are getting the one that is used in majority or in specialist cases and then raise the question. It may also drive increased specialisation in the profession and more attention to those being apprenticed, with their apprenticeships taking longer. I don't raise those issues to negate the positive intentions of this bill but to promote the debate about how this register will be structured. As my honourable friend Senator Askew has indicated, the government finds favour with the intentions of this bill and is seeking to consult to better understand how the registers will be constructed. I congratulate the mover of the bill for his dedication to advancing the interests of patients in Australia. I seek leave to continue my remarks later.

Leave granted; debate adjourned.