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|Title||National Association of Medical Specialists - A Failed Horatius|
|Publication Status||1 Nils Korner 2000|
|Copyright||Copyright of this article is vested in the author. Permissions for reprints or republications must be obtained in writing from the copyright holder. This article has been republished here with permission from the copyright holder.|
In the Begining
The Winds of Change
The Origin of NAMS
1972 -73 The Whitlam Government in Action
NAMS "Propositions Regarding a Workable Health Scheme"
NAMS Founding President, Boyd Leigh
Battlefield of Ideologies.
Into the Trenches: The NSW Medibank Hospital Seminars
Medibank Mark II
A New Teaching Aid - The Law
Back and Forth in Time and Place; From Canberra to NSW and Back
The Camel's Back
"What Good Came of it at Last?"
Horatius and Friends
If, as is more than likely, you haven't given Horatius a thought since your schooldays you may well be curious to find out what on earth he had to do with the National Association of Medical Specialists, NAMS for short.
Horatius, being a legendary character, is of course well known. With his friends he heroically defended Rome against invasion by stopping the Etruscan forces from crossing the bridge over the Tiber until the Romans had time to pull it down. Thomas Macaulay's Horatius at the Bridge brings him to life: -
"Now who will stand on either hand, and keep the bridge with me ?"
When the bridge had been demolished Horatius jumped into the river and swam back to the Rome he had helped to save.
As for NAMS, the National Association of Medical Specialists, regrettably only a few people (including doctors) can now remember its existence. In the 1970's and 1980's NAMS played a significant part in the still unresolved ideological conflict over the workings of the Australian health services and hospitals, the defence of Rome in this fairy tale. This account describes some aspects of that period, up to the crisis of the New South Wales Doctors' Dispute in 1984 and 1985. You must judge for yourselves whether NAMS and friends deserve to be compared with Horatius.
At the outset I must "declare" direct involvement with NAMS and its executive for some 10 years. If this gives rise to the suspicion of favourable bias the only counterbalance I can offer is a promise to try to stick to the record. One more word of explanation - NAMS was indeed a National organisation but New South Wales, the "Cockpit of Medical Politics" in Australia, is where the battle was most intense, and that's why it occupies centre-stage.
In the Begining
First a thumb nail sketch of the no doubt imperfect Health System of the 50's to the 70's. The Earle Page scheme was introduced in 1953 by the Liberal-Country Party Coalition Government.1 The Commonwealth subsidised voluntary private insurance by non-profit health funds by meeting part of the cost of the rebates for medical and hospital expenses. Membership of a health fund was necessary to receive the Government subsidy.2 Except in Queensland, where the hospitals offered free access to public care, those who "failed" the means test but were uninsured faced considerable medical and hospital costs.
The Honoraries were the backbone of the Hospital Service. They were specialists who cared for public inpatients and outpatients, taught students and nurses, trained junior staff, were involved in Grand Rounds, hospital administration and sometimes research - without pay for any of their "public" work . A means test and health insurance status classified patients into Public, Intermediate and Private categories. Public patients did not pay medical fees for inpatient or out-patient care at Public Hospitals. The Honoraries only income from their Public Hospital work was from fees charged to private and intermediate patients and later in this era they were paid (very modestly) by some Universities for teaching medical students. The proportion of salaried specialists in the hospital staffing profile slowly increased.
The Winds of Change
Pressure for change in the Health Service came from various directions. According to Scotton and McDonald 3 the key events making health insurance a major public issue were the accession of Gough Whitlam to leadership of the Labor Party in February 1967 and research undertaken at the Institute of Applied Economic Research in Melbourne University by John Deeble and Dick Scotton.
More visibly the Liberal-Country Party Gorton Coalition Government in 1968 set up the Commonwealth Committee of Inquiry into Health Insurance under Justice Nimmo. Gough Whitlam claims that this was merely a reaction to Labor's initiative in establishing (with DLP support) a Senate Select Committee to inquire into Medical and Hospital Costs in Australia. "[This](he says) was the first select committee that the ALP succeeded in having the Senate establish since 1951. Its greatest achievement was to compel the Gorton Government to establish a Committee of Inquiry into.. Health Insurance under Justice Nimmo . . ." 4
The Nimmo Committee 5 in March 1969 recommended, amongst numerous other things :
5. (1) That Standard Ward accommodation will be available to every member of the community regardless of means.....
(2) Intermediate and private ward accommodation will be available at the choice of patients. That the Commonwealth and State Governments work towards the integration of outpatient services into the Health Insurance Scheme
13. That there be established what are the most common fees being currently charged in each State for .... medical services ... That a medical benefits table be introduced in each State under which contributors will be entitled to benefits equal to the amount of the established common fee less $1.00
15. That doctors who wish their fees to be eligible for medical benefits should agree to participate in the scheme ; .... that medical expenses incurred to doctors who elect not to participate in the scheme be not eligible for medical benefits.
17. That there be adopted the policy for the gradual elimination of the honorary and concessional services rendered by the medical profession.
18. That an arrangement be developed whereby the established common fee for medical services might be adjusted at appropriate times on the basis of relevant economic indicators.
"..In March 1970 the Minister for Health announced that the Nimmo Committee's recommendations had been accepted by the Government. A year later Gorton made way for McMahon, who reversed the decision." 6 Certainly the Coalition Government took no action to implement the Nimmo Committee recommendations regarding hospitals.
The Labor Party's health policy had been laid down by the Federal Conference in Launceston in 1971. As far as hospital specialists were concerned the policy proposed "a national hospital service, including hospitalisation without charge and without means test , in public wards of public hospitals ...." " salaried in- and out-patient specialist staff " ".. Grants to the States to provide that patients in all wards of Public hospitals have the option of using, without charge, the services of specialists remunerated by salaries or sessional fees. " 7
But the Doctors were also ready to abandon the Honorary system. The NSW Branch of the Australian Medical Association (AMA) made a policy decision in Feb. 1969 "that the present system of honorary medical service in public hospitals should be terminated". 8
The Origin of NAMS
With the perception of a looming threat of nationalisation or at least of a radical transformation of hospital services the need for the medical profession to feel that its voice was being heard by Government became urgent. Amongst the Honoraries there was also concern that the AMA did not represent them sufficiently. In April 1972 a meeting "representative of all the specialist disciplines" was held under the auspices of the 3 year old Provincial Specialists' Association. It formed a steering committee of the National Association of Medical Specialists (NAMS), which published a Newsletter alerting doctors to the "attack launched by political parties and the mass media supporting them " and warned that "If the Labor Party is elected this year....it seems apparent from the Whitlam / Hayden proposals on Health Care Systems and Health Care Financing in Australia, that the first changes will be directed towards alterations in the hospitals' staffing status. "This ....will affect EVERY SPECIALIST throughout Australia."
"This meeting was remarkable for its unanimity and all ....agreed that a National Association of Medical Specialists should be formed as a matter of some urgency." 9
The Inaugural Meeting of NAMS was held at BMA House, Sydney on Saturday 29th April 1972.
One of its first resolutions was that NAMS should study Health policies in Australia and abroad so as to allow the medical profession to formulate its own recommendations for a Health System instead of merely criticising other proposals.
Was there a real need for an organisation such as NAMS ? The AMA, after all, attempted to represent the entire profession. The April 1972 NAMS Newsletter explained: - "It is frequently claimed that the medical profession consists of some 55% of General Practitioners and 45% of Specialists. This may.. be correct, but it is... misleading, because the '45%' has no cohesion and really consists of separate groups of 2%, 5% etc. of the whole. As such these groups are politically vulnerable....."
"[The] AMA. ....cannot wholly represent the interests of the full-time specialist without compromise.." 9
NAMS was confident that it ought to exist to represent the conglomeration of specialists and that it could and should do so better than the AMA.
1972 -73 The Whitlam Government in Action
Labor was elected on 2 December 1972 and the Government's White Paper on The Australian Health Insurance Program, tabled in Parliament on 8 November 1973, declared its intentions for Health Care : -
1.3 Patients ... will have the right of free accommodation and treatment as hospital patients in standard wards irrespective of their incomes.
1.5 .....the contribution of individuals to the Program will take the form of a levy of 1.35 per cent on taxable incomes. and
3.1 Medical benefits under the Health Insurance Program will be based on a schedule of fees.
3.33 ....Pathology and radiology services rendered by public hospitals [will] be included in the Australian Government - State Government cost-sharing arrangements and [will] not attract medical benefits...and
4.2 ....as a general proposition, [the Government] is convinced that the proper staffing of public hospitals........[is] best achieved through a system of salaried, sessional or contract service, rather than through fees-for-service for hospital patients. 10
NAMS "Propositions Regarding a Workable Health Scheme"
The Federal Council of NAMS established State Committees and in late 1973 the NSW Committee set itself the task of offering an alternative to Labor's plans by defining the principles of a Health System which the public, the Government and the doctors themselves, could all commend. The working party made a determined effort to examine critically every facet of the services provided by specialists in the public hospitals. The result was a document called "Propositions Regarding a Workable Health Scheme with Particular Reference to Specialist Practice" whose recommendations NAMS President Boyd Leigh outlined in a press release on 21 April 1974 :
1. Universal health insurance with Government assistance to those unable to meet the cost.
2. The co-existence of Government and private health insurance funds.
3. A flexible balance between different types of hospital practice with fee-for-service and sessional visiting doctors and full-time salaried doctors working together according to community needs.
4. A basic insurance premium covering family medical care, referred specialist care, diagnostic services.
5. A higher premium covering preferred (private) accommodation in public or private hospitals.
6. A negotiated schedule of fees.
7. Full inclusion of psychiatric care in the health scheme.
The "Propositions" received "most favourable" endorsement from a broad spectrum of Medical Organisations at a meeting held at the NSW Branch of the AMA on 30th June 1974.11 In contrast to this support it is interesting to record that Dr. George Repin, Federal Secretary of the AMA, formally requested Dr. Ronald Winton, the Editor of the Medical Journal of Australia (MJA), not to publish the NAMS "Propositions" "on the grounds that its appearance in the MJA may be misinterpreted having regard to the current medico-political situation. " (letter Dr.R.Winton to author, 18 March 1975). Boyd Leigh received an explanation from Dr. George Repin that "negotiations are fairly delicate at the moment, and as the NAMS document... suggests that payment for Standard ward patients be made by the authority, rather than directly by the patient....it [is] unwise to publish it at this stage." (letter Boyd Leigh to author, 27 March 1975). This was a misreading of the "Propositions" but Boyd Leigh had to accept that it was "fair enough to delay publication for a while". In the event the MJA never published the document.
The "Propositions" attracted a little ephemeral attention from the Press and the ABC, though, in an otherwise quite reasonable report The Australian (Monday 22 April 1974) managed to suggest that an "annual automatic increases in ... fees" was a primary objective . The Press liked to make out that money was the doctors' major concern.
NAMS also tried to present the specialist's perspective directly to the Government. The Executive met the Minister for Social Security, Bill Hayden, in February 1973 and key members of the Health Insurance Planning Committee (H.I.P.C.)., Messrs. Deeble and Scotton and L.J. Daniels from the Department of Social Security on 29th March . The most significant message they got was that the Government was determined "to introduce a sessional method of payment for 'visiting specialists' (at least in the case of the Metropolitan Hospitals). [This] was not due to any expected lack of funds to allow fee-for-service payment [but] simply...to give the Community the very best possible Hospital Service..... [A] Consultant Specialist Service employing fully-salaried staff backed-up by sessionally-paid 'visitors' is to be the only really satisfactory way by which to achieve this ultimate in hospital services ! " 12
NAMS Founding President, Boyd Leigh
A stocky and dynamic surgeon, Boyd Leigh was drawn into medical politics - first in the NSW AMA's Section of Surgery, later as Chairman of the NSW Committee of the Australian Association of Surgeons - by a study of the Nimmo Report and Scotten and Deeble's thesis on Health Insurance.. He was elected (unopposed) as the first President of NAMS at its first General meeting on 14 October 1972. Fortunately he has left a short account of his life.
He was born in 1920, the son of an Australian army officer and an English war bride. His father was a soldier settler who got a block outside Griffith on which he built a house and put citrus trees. He walked off the property and disappeared for many years when Boyd was four, so that he was brought up by his grandparents. They lived in various places, including Kings Cross and he went to school in Double Bay and Darlinghurst, did his QC at Cleveland Street Intermediate High School and went to Sydney High. At the end of fourth year when he was 15 he had to leave school because his grandfather was the licensee of the Pub in Redfern and he had to work there (illegally of course), as a barman.
This came to an end when the brewery reclaimed the pub and they had to leave. Next he worked for his uncle's second hand business in Mascot, buying stock at auctions and competing with some fairly tough characters. When he turned 18 the business could no longer afford the 17/6 per week wage so he had to leave, but with a bit of luck and influence managed to get two weeks casual work as a Counter Jumper in Woolworth's before Christmas. They were sufficiently impressed to keep him on the permanent, and later the trainee, staff.
When the war started he left Woolworth's and enlisted, ending up at first in the Darwin infantry battalion. By various adventures he left the Army and got into the Airforce but his pilot training came to an end when he crashed a Tiger moth in front of his instructor and he eventually finished up in Lancasters in Bomber Command and managed to get through that.
When he came home in '45 Woolworth's, who had promised everything before he went, wouldn't put him back on the Trainee Staff because he had been away longer than other people, and though they offered another pound a week and said they would keep him if he was up to scratch he told them in forthright manner exactly what they could do with their job. He bought a little grocery business in Redfern, got a hawker's licence, sold off the cart and delivered anything he had to order in on Saturday mornings. It was hard work and at the end of the year he thought he could do a bit better, looked up the Repatriation Act and found that if you had enlisted before you were twenty-one you were entitled to a guernsey in the form of Higher Education Post-War Reconstruction Training. The University Guidance Officer said "Oh no, you were only fifteen when you left school, you haven't done your leaving certificate, You're just not eligible" but Boyd said, "Oh, yes I am", produced the Repatriation Act and they looked it up together. The Guidance Officer had to say "I didn't know that.." and sent him to a Vocational Guidance test which showed that he could do anything he liked. Boyd chose medicine, which had been at the back of his mind for years, though he had given away any thoughts of ever doing it because he didn't have the educational background . He had one year to go back and matriculate at a special school in Pyrmont for Post-War Reconstruction people and at the end of that time he passed the exam and started medicine.
Here is his own description of how he fared : -
Well, I got through the medical course on £3/10 a week that the Repatriation Department generously gave us and some of you who have been through it doing one of the long courses might know that the day I graduated in medicine I got a bill for £1000 [from] the grateful government to repay part [of] the living allowance they'd given me. The only way I managed to get through medicine was to have a series of jobs and one of the most interesting .... was [as] a Medical Detailer. I had some medical background as a student and the firm gave me a part-time job in the holidays and I'd grab a car and a bag of samples and go around and interview doctors, and that was one of the most soul- destroying jobs I ever had because, I hate to say this, but some of my colleagues are terribly arrogant and if you were just a Salesman they treated you like dirt. ....
Anyway, after I got through medicine I did a few locum jobs and the usual residencies and things like that and eventually I started up as a GP in Engadine, in Sydney.... In those days GPs did cardiographs and internal medicine and delivered babies and gave anaesthetics and did surgery and over about six years I got a very wide experience that doctors today just don't get. At the end of the six years, and I do say this with some slight modesty, although, as I have said before, it ill becomes a surgeon to become too modest, it is out of character, but I'd done very well at surgery without being properly surgically trained and everybody was saying to me well why don't you go and get qualified. So I gave up the General Practice and I went to England and .. worked in the National Health and eventually I did the Edinburgh Fellowship and I qualified there.
Well, I continued on with a surgical career and I worked... all my life as an Honorary. In other words I was never paid by Medicare. In those days we had a means test which I think most of you will remember... and the poor people you operated on absolutely for nothing and the well-to-do people paid a legitimate fee. And I might say in passing, that when I finally retired... I would say I operated on about 40,000 people which is a pretty hectic surgical career ....."
Boyd Leigh died in 1998. Those ideologues who may want to portray all doctors as privileged silvertails would have difficulty fitting his life into that mould.
By early 1974 "The two Medibank Bills were twice rejected by the Senate and became two of the six Bills upon which a double dissolution was secured in April 1974. " 13 The NAMS Executive, innocently eager to leave no political stone unturned, hurried to ensure that each of the political parties had a copy of the final version of the "Propositions" before the election.
Labor won, but still did not control the Senate. Even though a joint sitting of Parliament passed the Medibank bills in August 1974 the Senate rejected the 1.35 percent levy bills and only after a decision to finance Medibank from general revenue was a starting date set for 1 July 1975.
Hospital Medibank required an agreement between the Commonwealth and the State Governments. In NSW this became effective from 1 October l975 and specified that "remuneration for medical services provided to hospital patients in recognised hospitals shall be
A by salaries
B by sessional payments or
C in special circumstances by contractual arrangements not involving fee for service paid by the patients...." 14
Battlefield of Ideologies. Sessional Payment vs. Fee for Service; Employment vs. Independence
Now the ideological conflict between the specialists and the politicians began in earnest. The options were perceived as "control" or "independence". The most bitter struggle occurred over the Government's uncompromising insistence that all those who were at that time honoraries should change to a system of sessional payment, salaries or a third option, "modified fee for service", paid by the hospital, not the patient, to doctors in rural hospitals.
The specialists were determined to stay self-employed on a fee-for-service system.
Why were the two sides so vehement ? Prime Minister Whitlam was Labor's driving force. In his book The Whitlam Government 1972-1975 he readily proclaimed that : "The single-minded self-interest of ...[the BMA and .the Australian Medical Association] has long been a stumbling block in the path of social justice as pursued by Federal Labor Governments." (p 330) ... "The ALP would have liked to reproduce the national health service which the Attlee Government had created as the most substantial and enduring of British Labour's reforms." (p332).. "While the constitutional position precludes the socialisation of doctors, it permits the socialisation of hospitals." ( Whitlam, 1961 Curtin Memorial Lecture).....'It is more important to nationalise hospitals than to nationalise the medical profession." (p334)... "Australia needs a hospital system staffed by salaried and sessional doctors. Hospitals must become the centre of medical care, as they are overseas, and not adjuncts to the doctor's surgery." (p338). 15
In their treatise The Making of Medibank 16 R.B.Scotton and C.R.Macdonald, without citing obvious supporting evidence, identified money as the determinant for Sessional Payment : "....state health administrators, ... favoured salaried and sessional payment, largely on the grounds of cost. In 1971 the conference of Commonwealth and state health ministers formally adopted sessional payment as the replacement for the honorary system in public hospitals." (p62)... "It was generally accepted that salaried and sessional payment would cost very much less than fee for service at current fee levels.4" (p. 159) [4Deeble's estimate was that the overall cost would have been between one and one-half and three times as expensive as salaried payment depending on location and specialty. ( Submission to MRC, 1976, p.4)p.172] 16
Bill Hayden, Minister for Social Security, attacked fee-for-service as "a payments system which encourages providers of the services to over-provide those services.." 17 Dr. Dick Klugman, ALP Member for Prospect likewise claimed that " the introduction of Medibank...has reduced the incentive to doctors to perform unnecessary operations because of the fee-for-service factor" 18
The labor ideologists and Press were eager to condemn the specialists for greed but professed not to see any contradiction between this accusation and the fact that the majority of doctors still preferred to work as "honoraries" rather than accept sessional payment.
On the other side the specialists regarded the prospect of becoming Government "employees" as odious. Instead of having many masters - their patients - salaried or sessional service would make them dependent on one powerful paymaster - the Government. They saw the arbitrary controls of their work conditions and income by legislation, ministerial regulation and bureaucratic edict as unendurable and the option of remaining "honorary" made impossible by the reduction in private patient numbers due to "free "hospital care and the abolition of the means test .
NAMS recognised that there were potential flaws in every system and recommended balance and compromise. Whilst fee-for-service could be misused to exploit patients for financial gain, sole reliance on salaried or sessional service could produce less spectacular but equally corrosive evils :- indifference, inertia, lack of direct responsibility or laziness, states of mind that are not unknown amongst employees of government or other large organisations. The weakness of the British National Health Service was seen as a relatively benign manifestation of this phenomenon ; in its extreme form it contributed to the failure of Communist societies.
NAMS argued that a patient contribution to fees restrains patients from trivial demands and makes doctors aware that their treatment has direct economic consequences for the patient, not merely for a faceless third party . Personal responsibility is imposed on both recipient and donor in health care.
There was another aspect of the cost controversy. Fee-for-service directly relates costs to the work done, regardless of the number of specialists doing it. A sessional system pays for time, not work performed, and thus applies pressure on administrators to cut costs by reducing the number of specialists and their sessional allocations regardless of the work load.
In contrast to their concern over the cost of Hospital fee-for-service successive Governments have remained deliberately blind to the exploitation of the public purse by medical services which are "free" at the point of service, exemplified by bulk-billing. In that "free" situation the doctor / entrepreneur may feel no qualms about doing things which are profitable but do not cost the patient anything and the patient may demand unnecessary services.
NAMS believed that the separation of patients into two categories, "hospital" and "private" inevitably led to a "Two Tier" system of hospital care. This was a valid criticism of the old Honorary system but applied equally to the new "sessional" hospital Medibank and Medicare. If the conditions attached to caring for "hospital" patients and "private" fee-paying patients were made different there would inevitably be differences in how they are cared for.
NAMS argued in vain that the best way to overcome this problem was to maintain a fee-for-service system for everyone, with a negotiated schedule of fees and an agreement on their reduction for social service beneficiaries. The "Propositions" also recommended that patients should be protected from an excessive fee burden by a limit to maximal costs.
There were other honourable failures. The inclusion of patients in State Psychiatric Hospitals in the health insurance system advocated by N.A.M.S. and the AMA fell on deaf ears and was not achieved under either Medibank or Medicare.
Not only hospital doctors felt threatened by the start of Medibank. On 1st June 1975 there was a mass meeting of doctors at the Wallace Theatre, University of Sydney, at which it was resolved that "this meeting of medical practitioners affirms its conviction that the Labor Government Health Scheme must lead to deterioration of Health Care and further damage the national economy" and "That this meeting of medical practitioners, realising that bulk billing would create an employer / employee relationship between government and doctors, declares its total opposition to this method of billing."
Into the Trenches: The NSW Medibank Hospital Seminars
The situation was not helped by the fact that the Government presented its formula as "not negotiable". NAMS first prepared Model Resolutions endorsing the "fee for service" system and rejecting sessional payment etc., which were sent to the Medical staff of every Public Hospital in NSW where, by February, 1975 they had received overwhelming support. In an effort to achieve maximal unity NAMS also prompted the NSW AMA to call together all the Medico-Political organisations to form a widely representative Conjoint Committee to develop policies. Its members included the NSW AMA, NAMS, the Australian Association of Surgeons (AAS), Australian Society of Anaesthetists (ASA), and representatives of the various Royal Colleges.
In New South Wales Hospital Medibank commenced on 1 October 1975 without any negotiated agreement on the doctors' working conditions. If they were to be paid for looking after "hospital" patients only sessional service or, for rural doctors, "modified fee-for-service", (both at a rate determined by the Government) were allowed under the Commonwealth / State agreement. This was regarded as "industrial conscription" and the doctors attempted to make the Government negotiate. The Medibank Seminars became the most significant instrument for achieving this objective. Initiated by the NSW AMA under the presidency of Dr.Ted Morgan even before the commencement of Medibank, the Seminars were assemblies of doctors, honorary and salaried, often between 100 and 200 in number, from the public hospitals, metropolitan and rural, large and small. They voted the collective will into Resolutions which provided their negotiators with direction and strength. The first Seminar, in February 1975 gave overwhelming support to a fee-for-service system and rejected the changes that were to be imposed, sessional payment, free outpatient and inpatient treatment for all without means test and so on.
Whatever the NSW Coalition Government may have wished to do it was bound by the Commonwealth / State agreement which it had signed. The result was an impasse and a seemingly unending succession of Seminars - two in June 1975, another in August, September, October and November. On 29th June, 1975 there was a shudder of recognition of the Governments' power . The Seminar remained of the opinion that "fee-for-service" to the patient should be the: primary basis for further negotiations but contemplated the possibility that " If this was unattainable the executive officers ... were to urgently explore with the NSW Government all methods of applying in parallel "time based" and "Fee-for-Service (other than to the patient) contracts for the treatment of hospital patients."
In October 1975 the start of Hospital Medibank revitalised the determination to resist the imposition of "sessions" and the Seminar decided to suspend routine Hospital Outpatients, though "certain specialized outpatient departments" were allowed to continue. But if the Government succeeded in dictating a sessional system it should at least be fair. By 23 November 1975 the Seminar resolved "That....recognising that some doctors are willing to accept 'sessional service' [the Seminar] recommends acceptance of an Independent Statutory Arbitral Body (of one judge and two others from each side) to determine conditions of service and levels of remuneration for 'sessional' and 'fee-for-service to the hospital' contracts". Routine Public Hospital Outpatients would stay closed.
The situation with regard to the Commonwealth Law was also discouraging. Section 17 of the Health Insurance Act 1973 denied "hospital" patients in "recognised" hospitals a Medibank rebate for medical services. Section 18 denied a rebate for diagnostic services to all patients in a recognised hospital regardless of whether they were "hospital" or "private". By November 1975 a challenge in the High Court against the validity of Sections 17 and 18 of the Health Insurance Act 1973 had been initiated by the NSW AMA and Dr. Roger Dunlop for GP's, Prof. Tait-Smith for Pathologists, Dr. P. Grattan-Smith for Radiologists, Dr. Boyd Leigh for Surgeons, Dr. P.Butler for Physicians and Dr. F.L.Broderick for Nuclear Physicians. This faltered after the Whitlam Government fell, partly because of the possibility of devastating legal costs but also in the hope - the vain hope as it turned out - that the Fraser Government would repeal the offensive Sections of the Act.
The accelerating crisis in Australian politics came to a head in November 1975 with the dismissal of the Whitlam government. The election that followed in December swept Malcolm Fraser at the head of the Liberal - Country Party Coalition to power.
Medibank Mark II
Mr.Fraser had promised to retain Medibank during the election campaign, but after coming to power he was quick to set up the Medibank Review Committee (Chairman Mr. Austin Holmes), to which NAMS restated its major policies. The Fraser Government soon established that it was as good at failing to consult as its predecessor. It took 9 months from the election before NAMS representatives got an interview with the new Health Minister, Mr. Ralph Hunt.
The complexities of the Coalition's modifications of Medibank are too convoluted to describe here in detail. At first the levy on taxable income was raised to 2.5% but it became possible to opt out into private health insurance, or, in the case of lower incomes, hospital only insurance. Charges to private patients in public hospitals would increase ; doubt was cast on the validity of the Commonwealth State Medibank hospital agreements etc.19 The Labor Opposition and the ACTU, led by its President Bob Hawke, objected sufficiently to mount Australia's first National Strike on 12 July 1976. "Shipping, international and domestic flights, public transport and most industry would stop", the Sydney Morning Herald reported on the day, " and schools, deliveries of milk and bread, postal services and funerals [would] be disrupted". The next day the Herald Editorial reflected that Australia had come through "unparalysed". Many workers and some unions had ignored the strike, the Government would not give way and the episode could "give little rational satisfaction to either side".
The Fraser Government was not getting a good press. A Sydney Morning Herald Editorial on 29 September 1976, lamented that "Medibank Mark II ... must be considered the most notable political and administrative ineptitude of the present Federal Government's first year in office..... It has caused massive confusion..... The report of the Medibank Review Committee, which presumably offered a solid basis of justification for the drastic changes, was not published. Soon after announcing the new scheme, the Government was forced to back down, change its mind and introduce Medibank Private."
A New Teaching Aid - The Law
By 1978 the Budget abolished the 2.5% Medibank levy and it was no longer compulsory to pay for health insurance. The Canberra Times (25 October 1978) reported that as a result "about four million people [would] drop out of Health insurance altogether and rely...on the universal 40% Commonwealth refund for medical services and on the universal free hospital accommodation and treatment provided in the scheme ..". The Opposition and some elements of the Press tried to create the impression that there was now no need for private health insurance, but the Government was anxious to increase the numbers of the privately insured. On 20 October 1978 Mr. Ralph Hunt, Minister for Health, had written to the Sydney Morning Herald : -
"Sir, ..... I reject as totally irresponsible the advice that has been given by some people that private health insurance will be no longer necessary after November 1.....people in Australia have shown a predisposition to be treated by the doctor of their choice in hospital. ... if they desire to maintain this right to doctor of choice, they will need to retain their private medical insurance ....."
The NAMS Federal Council also decided that a notice in the newspapers setting out the differences between insured and uninsured patients in public hospitals would be appropriate. The advertisement, perhaps simplistically, summed up the Uninsured Patients' rights in one word : NONE. The Insured had Rights to the Doctor of their Choice, a Second Opinion, Access to or Dismissal of their Doctor. PRESERVE YOUR RIGHTS BY MAINTAINING BOTH HOSPITAL AND MEDICAL INSURANCE, it proclaimed.
On the day this appeared in The Australian (20 October 1978) NAMS Executive Director John Gibson, replying to a letter from Mr Hunt, also guilelessly informed him of the NAMS advertisement. But on October 23rd The Australian reported that Mr. Hunt was upset, and that it was "not true that people who accepted treatment [as uninsured hospital patients] would have no rights". He had referred the Advertisement to Mr. Fife, Minister for Business and Consumer Affairs, for possible action under the Trade Practices Act. Presently John Gibson, together with the printers, publishers, and proprietors of The Australian were served with an Order from the Trade Practices Commission, to "TO SHOW CAUSE" in the Federal Court of Australia why they "should not be restrained from .....Publishing or from causing or permitting to be published any other advertisement or statement which represents that persons uninsured for hospital treatment ...have no rights (or less rights than they in fact will have) in contrast to persons who are so insured " or " in any way aiding, abetting, counselling ....any person to" publish such a statement - or to be ".... party to the said conduct " 20 !
Heavy crimes indeed ! Efforts to call off the vengeful pack of legal hounds failed, though it was not difficult on behalf of John Gibson to quote Mr Hunt and other government authorities in vindication of the truth of the advertisement. To be (insured) or not to be (insured) was clearly not quite the same, but with the majestic machinery of the Law set in motion it was too late for reason or restraint.
The Federal Court hearing was adjourned to 13 December provided the offending advertisement was not republished. Counsel for the Newspaper said that they would argue that their contravention was a reasonable mistake or due to reasonable reliance on information supplied by another person or the default of another person etc. etc. N.A.M.S. could end up liable for all their costs.
If NAMS didn't argue that the Advertisement was true it could be found to have aided and abetted in the publishing of misleading or false information and pay heaven knows what costs all round. If the advertisement was proved to be true or believed to be true N.A.M.S. could still be liable for its own costs. Even if the court held that the advertisement was true the Trade Practices Commission could appeal .
Faced with a bottomless whirlpool of legal costs NAMS only choice was to raise the white flag and surrender. John Gibson had to undertake and promise not to republish the offending notice or to aid or abet in its republication . As a further condition of settlement the Crown insisted on NAMS paying its legal costs as well. And the Court so ordered !
NAMS Bulletin No. 21 - January 1979 reported that "the Legal costs to date are $5,753, and we can anticipate further charges after Court taxation has been added."
Whether the NAMS advertisement was true or not seemed to have become irrelevant. But it would be wise to remember that the authorities know how to teach anyone who thinks that telling the truth gives them a right to get cheeky a sharp lesson : - Legal Costs !
Back and Forth in Time and Place; From Canberra to NSW and Back
In NSW the "Statutory Arbitral Body" which was meant to make sessions more acceptable had not eventuated but the Willis Coalition Government appointed a Queen's Counsel, Mr.Andrew Rogers QC, as a Private Arbitrator. He started hearing a log of claims on the terms and conditions for sessional visiting medical officers caring for "hospital" patients on 28 April 1976. Fee-for-service contracts were "not available".
Disappointment with Arbitration was swift. Mr. Rogers suggested that a Senior Specialist should get an hourly rate of $ 16.82, (brought up 20 % with leave provisions to $20.18 ) compared to hourly pay for Junior Counsel of $ 40.00 to $ 55.00 (add 50 % for a QC ). The NSW AMA Monthly Bulletin (27 December 1976) reported the "Arbitration findings by Mr. A. Rogers, QC " ...were unanimously rejected by the Medibank Hospital Seminar ....on September 19  as being both professionally and industrially unacceptable."
In February 1976 the NSW Health Commission had accepted the closure of routine Outpatient Clinics but the Wran Labor Government replaced the Coalition on 1 May 1976 and by October it announced the intention to reestablish outpatients and to provide General Practitioner services in Public Hospitals. Mr. Wran's Government devised a succession of control mechanisms to enforce obedience. First it required the specialists to apply for appointment to an entirely new invention called a Visiting Practitioner (Government Gazette 150, 9 December 1977). The doctors' current Visiting Medical Officer (VMO) appointments were not good enough - a fresh application as for a new post was required. The terms of appointment were left unclear but the NSW Health Commission gave itself virtually unlimited powers to introduce regulations governing the doctors' work - the granting of (clinical) privileges, their revocation, the powers of Credentials Committees etc.
Visiting Practitioners would have rights of appeal against Hospital Board decisions but the Health Commission itself could determine the appeal or appoint a Committee of Review whose decision would be final. Without appointment as a Visiting Practitioner the Visiting Medical Officer had no right of appeal.
On 1 July 1978 the Fraser Government reduced the benefit for patients other than "eligible" pensioners treated in public hospitals from 85 to 75% of the schedule, with a maximum gap of $10 instead of $5. The NSW Health Commission promptly and without consultation announced that the Rural Doctors who were on "modified fee-for-service" contracts would now get these reduced rates regardless of any existing agreements.
In March 1979 NSW Health Minister Kevin Stewart threatened to control doctors' private fees and on 3 August 1979 Mr.Sid Einfeld, Mr.Wran's Minister for Consumer Affairs, "declared" doctors' services, and set up the Prices Commission Inquiry into Private Medical Fees, the necessary steps towards regulating them. Such treatment of a professional group was without precedent in NSW history ; but eventually the Wran Ministers' assault failed.
In case there was still any doubt about the mindset of the NSW Government the NSW Parliamentary Public Accounts Committee tabled a report in the Legislative Assembly on 6 April 1982 which recommended : "That, as a condition of appointment, all visiting medical practitioners be required to charge no more than the medical benefit schedule fee ...to private patients in public hospitals" ; Sessional payments for ..services provided to "hospital" patients be extended to all public hospitals ; Visiting medical practitioners be remunerated for medical services to all patients in New South Wales public hospitals on a sessional rather than fee for service basis. The Public Hospitals Act be amended to prohibit charges being raised by any medical practitioner for services provided to a patient in a public hospital." In short, private practice in Public Hospitals would be eliminated.
The Camel's Back
On 5th March 1983 the Fraser Government was defeated and Labor under Bob Hawke took power with a majority in both the House of Representatives and the Senate. The new Labor health scheme, Medicare, a resurrected variant of Medibank, was ushered in by Dr. Neal Blewett, Hawke's Health Minister, on 1st February 1984 (except in Queensland, where it started on 5th March). A great deal was familiar : Bulk-billing, "free" treatment in hospital, a compulsory levy, at first 1% of gross income. For the doctor of their choice patients had to buy additional insurance; "Gap" insurance was prohibited and the Government's Medibank Private had a monopoly for the administration of basic medical benefits.
This time, hidden in the legal verbiage of the new amendments to Section 17 of the Health Insurance Act was the ultimate control mechanism which evoked a storm of real outrage amongst hospital specialists.
Clause 18 of Section 17 required "that contracts between Visiting Medical Officers and Hospitals for the care [of] both public and private [patients] shall be acceptable to the [Federal] Minister". He could change the guidelines at will without the agreement of the contracting parties and without appeal. The contracts became invalid if they did not conform. Medicare benefits would not be payable to private patients at public hospitals unless the practitioner has entered into an approved agreement with the hospital.21
The Federal Health Minister had given himself unfettered power to dictate the contracts which the visiting specialists had in the past negotiated with their State Health Departments ; the guidelines could control not only fees but also conditions of service.
In NSW the Public Hospitals Amendment Act also gave the State Health Minister draconian powers. "Clause 42(1)(h1) provide[d] that regulations may be made under the Act with respect to the appointment, management and government of visiting practitioners, including the conditions subject to which visiting practitioners may perform work at the hospitals.
Clause 42 ( I A) made provision for [regulations on] : - (a) the conduct of a visiting practitioner of a hospital (whether at a hospital or elsewhere) in relation to the performance of work which is capable of being performed at the hospital by the visiting practitioner;
(b) any conduct of a visiting practitioner of a hospital (whether at a hospital or elsewhere) which may prevent or inhibit the admission of persons (whether or not those persons are members of or subscribers to any organisation) to that hospital. [This meant that the Minister could punish doctors for persuading patients to take out private health insurance before admission to a public hospital].
The Minister also determined to proclaim the 1976 amendment to the Public Hospitals Act which related to the formation of credentials committees in public hospitals." [NSW AMA Monthly Bulletin, 30 January 1984]
It was a recipe for confrontation, the straw that finally broke the camel's back. The specialists clamoured for repeal of the obnoxious laws.
A Seminar on 18 December 1983 unanimously advised hospital doctors "to have nothing to do with contracts that contain Clause 18 provisions of the Health Legislation Amendment Act" ; "declared it had no confidence in the NSW Minister for Health (Mr Brereton) and called for the resignation of the Federal Health Minister (Dr Blewett PhD)".
Dr. Blewett poured petrol on the flames. On 28 February 1984 the Sydney Morning Herald reported that "NSW diagnostic specialists ....will receive a letter this week warning that medical benefits will not be available to their patients if they continue the dispute."
Negotiation and reason had failed. There seemed to be only one recourse. The withdrawal of non-urgent procedural and diagnostic medical services commenced in early March 1984. The Sydney Morning Herald [17 March 1984] professed to see "Dr Blewett's power under Section 17" as innocuous, " certainly no more and probably a great deal less than that of any other employer. In theory he can do almost anything he likes. In practice, he is limited by both the doctors' industrial power and public opinion". The Herald showed a tiny flash of insight into what the conflict was about - " the first skirmish in a long struggle over who - the doctors or the Governmentwould effectively control the medical industry ...."
With threats of industrial action spreading, the Minister [Dr.Blewett], in March, rushed through Parliament a provision subjecting his guidelines to parliamentary scrutiny and disallowance. [H.Lindsay Thompson. The Doctors, Medicare and Private Hospitals. Medical Journal of Australia, 15 September 1984 p.376.] Jim Carlton, Opposition spokesman on Health, again raised the issue of the High Court deciding the constitutional validity of Section 17 in Federal Parliament on 29 March 1984. But for the specialists anything short of repeal of Section 17 was not enough.
The NSW Government staged a further ambush by suddenly gazetting Regulation 54A of its own amendments to the Public Hospitals Act. The Sydney Morning Herald (2 April 1984) reported this as meaning "that unless a visiting Practitioner at a public hospital charges [private patients] the schedule fee or less, that doctor can lose his or her appointment at a public hospital." Mr. Mulock, the NSW Minister, was empowered to dismiss doctors.
The NSW doctors voted for a withdrawal of all but emergency services for a week from 9 April. The Sydney Morning Herald (3 April 1984, p.10) gave them some Editorial advice on their "strike": NOW IS THE TIME TO QUIT : - ".... The doctors... are heading towards industrial defeat. Their obvious hope was that the threat of a national strike would panic the electorate and the Government. That has not happened. The Government clearly believes that the doctors are incapable of sustained, widespread industrial action." With seeming satisfaction the Editor explained why they were weak : - "The main reason for expecting next week's strike to collapse is the natural reluctance of individual doctors to turn all but the most non-urgent of cases away. That has been the experience... so far, and there is no reason to believe that doctors have suddenly become more ruthless."
An uneasy truce shortened the withdrawal of services from a week to only 2 days. But the NSW Government refused to withdraw its regulations and by June '84 a growing number of surgeons, orthopaedic surgeons, anaesthetists and many other Visiting Medical Officers had resigned from NSW Public Hospitals.
Mr. Wran responded by legislating to ban "for seven years any visiting practitioner who left the public hospital system. He would publish these doctors' names, effectively preventing their re-engagement by New South Wales hospitals " ; by June 15 the Government had forced through both Houses the " Public Hospitals (Visiting Practitioners) Amendment Act." (NSW AMA Monthly Bulletin 25 June 1984, p 8) Those who published the resigned doctors names would be protected from defamation suits. Resignations submitted on or after 26 May 1984 would be rendered null and void by the Act. "But if they were determined to resign replacements for them would be found" [Sydney Morning Herald 19 June 1984 p.1].
Mr. Wran had succeeded in uniting the profession where others had failed !
Once more the NSW AMA recommended [on 17 June 1984] that only emergency services be provided and more resignations started on 20 June. On 21 June 1984 the Sydney Morning Herald reported [The public relations Battle for the heart of Dr.Chang Yvonne Preston, p.1] that Dr. Victor Chang, head of Cardiac Surgery at St. Vincent's Hospital and personal friend of Mr. Wran's, had tendered his resignation on Monday 18 June.
"....On Tuesday Mr Wran requested another meeting with Dr Chang. That evening Dr Chang said on television he had not wanted to resign, but he did not want to see nationalised medicine as he saw it in England "When I came home, I thought, the Australian people are the luckiest in the world They have the best public health service in the world." The implication was that the Government of Neville Wran was about to wreck it. ......
Dr Chang said: "All of us in training say, 'let's go to England to operate on the British public. We know we are going to be able to do a lot of cutting. It's a very crude word. I don't like to use it. We are often not supervised. The reason is that senior doctors in England in the National Health system have no incentive, either money or the pursuit of excellence, to spend time to look after these people. And we come back with great experience, which we pass on to the Australian public. We could end up like England" .
A six member medical "Negotiating Body" and a legal representative listed the conditions for resumption of talks with the NSW Government but a meeting between Convenor, Dr. John Dixon Hughes and Mr.Wran on 23 June achieved nothing.
Mr.Wran was at last forced to announce what the Sydney Morning Herald (28 June 1984) described as "a major retreat" - his intention to repeal the 7 year ban.. In fact he then decided to "defer the repeal until an unspecified time in the August Parliamentary sittings and in the meantime to proclaim that section of the Act which purported to nullify all resignations already submitted."(NSW AMA Monthly Bulletin 30 July 1984 p.7). The resignations which had started again in June were not lifted until the NSW Parliament repealed the 7 year ban legislation during its September 1984 sittings.(NSW AMA Monthly Bulletin 29 April 1985 p.12)
But the Federal and State Legislation giving the respective Ministers power over the specialists' working conditions was still in place and the NSW Government refused to move from its derisory sessional offer or the unrelenting rejection of fee-for-service. The mood was one of bitter frustration and the NSW AMA Branch Council and chairmen of hospital medical staff councils in late October felt themselves forced to recommend an indefinite withdrawal of services from all Public Hospitals. In November 1984 the chaos got worse. The rift between the ASOS and AAS and the AMA, caused by their doubts (correct or otherwise) about the AMA's capacity and will to carry the struggle to a successful conclusion, became public when the Press reported that Drs. Shepherd and Aroney of the ASOS and AAS respectively had withdrawn from the doctors' negotiating committee. Mr Justice Macken was nominated by the NSW Government as arbitrator but the AMA rejected this as inappropriate because the arbitrator had no power to resolve the principles in dispute. The Royal Colleges met the State Minister to urge direct negotiations.
The NSW Government still refused to negotiate and the AMA called for escalation of industrial action. NAMS' "The Specialist" No.52, December 1984 reported that "The N.S.W. Hospital system is still functioning but...is approaching a state of breakdown". The offer by Dr. Blewett and Mr. Mulock of yet another inquiry was rejected by the AMA.
On 2 January 1985 the Doctors Coordinating Committee wrote to Prime Minister Hawke pointing out that the dispute with NSW involved Federal Government policies and that he should intervene . On 17 January Mr.Hawke and Senator Grimes, the Acting Health Minister, with Mr.Wran and Mr.Mulock met Dr.H.L.Thompson and Dr.Buhagiar Presidents of the Federal and NSW AMA, and Drs. Bruce Shepherd and Michael Aroney of the Australian Society of Orthopaedic Surgeons (ASOS) and Australian Association of Surgeons (AAS), Dr.Judith Williams of NSW Australian Society of Anaesthetists (ASA) and Prof. John Hickie, President of the Royal Australasian College of Physicians (RACP). Another meeting, on 23 January 1985, was held without Drs. Shepherd and Aroney, who had advised that they would not be present. The Prime Minister and Premier Wran produced a four-point "package" on a take-it or leave-it basis. They promised, amongst other things, to " give an unequivocal public undertaking that it is not their intention, or that of the ALP, now or in the future, either directly or indirectly to abolish private practice within or without public hospitals, or to nationalise medicine" and that " both Governments are prepared to enter into direct negotiations with the medical profession on the methods of remuneration for medical services provided to public patients in public hospitals" [NSW AMA Monthly Bulletin 25 February '85 p.12] but demanded that the doctors must be advised to withdraw their resignations and return to normal duties in public hospitals before the dispute could be settled.
This precondition was the unacceptable sticking-point and was rejected by both the NSW AMA and the Council of Procedural Specialists. The division between the Procedural Specialists, ASOS and AAS, led by Drs. Shepherd and Aroney and the AMA got worse, fed by the fear that the AMA would allow the Government to manoeuvre it into recommending a premature return to work which would nullify everything that had been gained . A visit to the Prime Minister by the Council of Procedural Specialists without the AMA on 20 February 1985 aggravated the discord - but these talks failed. Mr. Hawke then rang AMA President Lindsay Thompson and invited him to a meeting without any precondition on 21 February 1985 - Mr. Mulock was also present. Lindsay Thompson felt that an agreement for negotiations had been worked out but did NOT agree to advise withdrawal of resignations. [NSWAMA Monthly Bulletin 25 March 1985 p.11]. "[The] government agreed to drop its... insistence on withdrawal of resignations as a prerequisite to talks. The AMA, however, had to agree to an extensive publicity programme calling on doctors to resume normal duties". [NSW AMA Monthly Bulletin 29 April 1985 p.12]. But there was no real progress regarding the obnoxious legislation. On 31 March 1985 an Extraordinary General Meeting of more than 700 members of the NSW AMA recommended that all Visiting Medical Officers should resign forthwith. This was endorsed by the NSW Branch Council on 2 April 1985. [NSW AMA Monthly Bulletin 29 April 1985 p.4]
At last, with their backs against the wall, the doctors had cried out in a language the politicians could understand. On 2 April 1985 the Commonwealth and NSW Government in a joint Press Release produced another "package" for settling the dispute which at last took the doctors' demands into account : - Section 17 would be repealed ; modified fee-for-service (ie. paid by the hospital) would be offered for peripheral hospitals at three levels related to resident staff support ; on admission to hospital patients with Private Health Insurance would be classified as Private ; the Commonwealth would hand regulation of Private Hospitals back to the States. The Government acted tough by presenting the package as "the bottom line" which would be withdrawn if not accepted within a month. [ Circular letter AAS, 10 April 1985].
The Sydney Morning Herald [3 April 1985] trumpeted a "cave in.... to the demands of militant NSW doctors" by the Federal Government, and the Editor pronounced that the offer had gone "too far. The Government has offered fee-for-service for the treatment of public patients in all but the teaching hospitals. At the same time, with its offer to repeal the original amendments to Section 17 of the Health Insurance Act, it has walked away from its responsibility to control costs in the hospital system. The taxpayer... is to provide open ended funding for fee-for-service medicine... " Mr Wran could not resist firing one more salvo at the hated enemy. "If this very reasonable proposal was rejected by a substantial number of doctors," he warned "he would recruit replacements from interstate and overseas."
The mass resignations had at last forced the Federal and State Governments to listen. By May 1985 the work of the Public Hospitals had more or less resumed. The division between the AMA and the AAS and ASOP which had been such a dangerous threat to success was patched over but not healed .
Any feeling of victory was quickly dissipated. The long war of attrition resumed and has continued. By July 1985 the NSW AMA Branch Council was again sharply criticising the three months delay by the government in carrying out specific undertakings and Dr C.S.H. Reed described a "seething cauldron of discontent among doctors....."
I have spoken of NAMS as if it were an abstraction, but of course it consisted of numerous diversely talented individuals - all of them actively involved in patient care, but at the same time willing to give their time, experience and energy to defend of the medical profession's independence and try to develop sound health care policies. Boyd Leigh's successors as President were Rob Kelsall - Pathologist, Colin Selby Brown - Orthopaedic Surgeon, Frank Croll - Physician, Tom Orban - Pathologist and finally Richard Prytula - Psychiatrist. Each of them carried the burden of responsibility which falls on presidents and made their particular contribution, enriched by the experience of their specialty. Less visible but just as important were the many Secretaries, Vice-Presidents, Treasurers and Councillors, who spent long hours in thought, discussion, debate, writing, travelling, persuading and lobbying in pursuit of the aims NAMS had set itself - the word "catalyst" was often used to describe how it might fulfil them :- achieving the highest standards of Specialist Practice in the best possible system of Health Care. There were honoraries and salaried full-time staff specialists, academics and pragmatic rural doctors, eminent persons and footsoldiers who came from all over Australia. Space makes it impossible to list hem all, but it would be wrong not to mention some (apart from the Presidents ) who made remarkable contributions - Alan Hewson - Obstetrician and Gynaecologist, Lee Evered - Radiologist, Stuart Taylor - Urologist, Peter Dawes - Pathologist, David Wallace - Physician, Ian Collins, Physician - and there were many others to whom I apologise for not recording their names.
Another key contributor to NAMS fortunes was John Gibson, the Executive Director who was appointed in July 1977 when, with the sounds of battle all around, it became obvious that the amateur Councillors who were all in specialist practice could not also find the time and energy to cope with the affairs of NAMS without professional help. John Gibson was not a doctor, but quickly understood the hospital specialists' problems and espoused their cause with enthusiasm and devotion. A wiry man of military bearing, unfailingly courteous, diplomatic and efficient, he worked for NAMS full-time until he retired in November 1983. After returning to the Sydney area from Melbourne in 1985 he again worked for NAMS part time. [ NAMS The Specialist No.56, November 1985]
"What Good Came of it at Last?"
NAMS made a crucial contribution to the various Action and Conjoint committees and the NSW Hospital seminars which inspired the resistance to the conditions imposed on hospital doctors by Government from the start of hospital Medibank in 1975. These efforts helped to achieve strong solidarity at the beginning, but when the conflict dragged on for many years the simultaneous pull of opposing forces made it much more difficult to maintain unity. On the one hand was the necessity to oppose the governments' control policies, even at some personal cost, if the profession's independence was to be maintained ; against this was the need to earn a living, to survive, to look after sick patients, even if it could only be done on the Governments' terms. The quarrel within the medical profession, between the major Medical Associations and the AMA, was about defining the difference between the middle path and the path of least resistance, between compromise and surrender. The State Branches and the Federal AMA were also not always in step. In N.S.W. NAMS put fire in the belly of the State AMA in the most direct way possible - in 1979 six of the seven seats for Specialists on the AMA's Branch Council were held by members of NAMS [NAMS Bulletin No.24, July 1979]. But when in 1978, encouraged by the success of the NSW Conjoint Committee, NAMS invited the major medical associations and the Royal Colleges to form a national body that could advise the Commonwealth Government on the provision of specialist services in hospitals the proposal was rejected on the grounds that their annual joint conference with the AMA fulfilled that objective and, in the case of the AMA, because they already adequately performed the intended function. [NAMS Bulletin Nos. 19, 20, July, September 1978]. Yet by 1979 the A.A.S. had disaffiliated from the AMA [NAMS Bulletin No. 22, March 1979] and their relationship remained hostile.
When the conflict over the dictatorial Federal and NSW Health Legislation became a crisis in 1984 and 1985 only the withdrawal of services and mass resignation from the public hospitals, notably by the surgeons and orthopaedic surgeons, was sufficiently powerful to influence Governments. NAMS was by then not in the front line.
But even before Medibank started NAMS, with some justification, claimed the intellectual vanguard - most significantly because it grasped and acted on the conviction that the doctors' first hand experience of hospitals and patients gave the medical profession a capacity beyond that of politicians and economists to formulate a practical and fair health scheme. The result was the "Propositions Regarding a Workable Health Scheme" and the subsequent updated 1987 publication "Proposals for a National Health Scheme" .
Whilst the NSW Branch of the AMA and other major associations endorsed the "Propositions" the Federal AMA lacked even the modest courage needed to allow its publication in the Medical Journal of Australia. One can only speculate on what might have happened if the AMA and other medical organisations had united to press the Government to accept their own coherent Health plan. Incredibly it took until 1987 before a resolution put to the AMA Federal Assembly by the then President of NAMS, Dr. Tom Orban, made the Federal AMA formulate a health policy. He described the scene. The discussion had rolled on for hours before "the most important item was finally debated.... motion, "10.3" as amended : "That Federal Assembly instructs Federal Council to draft the principles of a National Health Care Plan which will be in the best interests of the Australian people".
"Before I tell you the outcome" he wrote "I also have to tell you that it became quite clear...that the matter would not be dealt with until well into the late afternoon. I sent a note to the Chairman that I would be grateful if I could circulate some 20 copies of NAMS' "Proposals" during the lunch intermission....".
The vote was not unanimous but the motion was [approved by] a large majority. [T]he ..Assembly was visibly and audibly jubilant that after some fifteen years of trying we have now irrevocably directed the Council to get on with what NAMS has advocated for almost that number of years." [NAMS The Specialist, No. 65, June 1987]
When some two years later the Federal AMA mountain finally went into labour it brought forth a document called "Medicover - Reform of Australia's Health Insurance System (Green Paper)" prepared by Access Economics (May 1989). It is fair to say that the Government of the day treated it like any other outside advice on the Health Insurance System - with even-handed disregard.
At the height of NAMS activity, around 1974 -75 there were some 1500 members ( probably between 20-25% of the total number of approximately 7000 specialists in Australia at that time). 22 In 1994 the last President of NAMS, Dr. Richard Prytula, a Victorian Psychiatrist, reported that ".. the membership of NAMS has declined progressively since its highest peak .... NAMS is in a good financial position but I believe the inevitable outcome is its dissolution.". [NAMS President's Report, October 1994]
In 1995 the Federal Council decided to disband NAMS. The Articles of Association required that any residual funds were to be distributed to an organisation with like aims. On 17 December, 1995 Dr. Prytula informed the members that "The Association has been merged with the Australian Doctors Fund Limited. Your President and Secretary are involved on the Committee of Management of the ADF. This allows us to continue to try to effect beneficial change in issues concerning all specialists in the Australian Health Care scene."
The flame of resolve had burned down. After 23 years NAMS had run its course.
Horatius and Friends
There is no doubt that a brave band stood on the bridge to defend Rome : - the State and Federal AMA, NAMS, the AAS, ASOS, ASA, the Chairmen of the Teaching Hospitals, representatives of Rural Doctors, General Practitioners, the Royal Colleges and many others, groups and individuals. It was often hard to distinguish which one of them was Horatius.
Did they hold the bridge or were they overwhelmed ? Did they succeed or fail in their task ? No and yes ; yes and no.
Driven to the extreme of resignation from their hospitals the specialists and their medical associations achieved the repeal of the disgraceful Federal and State legislation which attempted to put the medical profession in shackles. Without their remarkable perseverance medicine and the hospitals would have been effectively nationalised. They succeeded in allowing private practice to survive, though under threat ; in not becoming government employees, however dependent on government money ; in preventing matters from becoming considerably worse.
But the barbarian hordes did cross the bridge, pillaged "Rome" and have wrought a great deal of destruction. The Health System and Public Hospitals remain in disarray. Politicians continue to be impervious to empirical advice. Successive Governments have relentlessly bought votes and power with the currency of the economists and bureaucrats - a "free" health and hospital system operated by a controlled medical profession - even if the price is the antithesis of reform - a mutinous workforce and the relentless decline of health and hospital services. The costly "free services" prescription has become politically addictive.
The morale and ethics of the practice of Medicine have been corrupted, notably by the scourge of bulk-billing, which has brought opportunists - doctors and business - to swill at the financial trough and has caused a haemorrhage of funds from where they are needed - hospitals, mental health, medical research - into the pockets of the entrepreneurs. "Political correctness" about the benefits of the historically abhorrent concept of medical advertising has encouraged the promotion of conjuring tricks and snake oil rather than medical expertise.
Instead of cooperation and goodwill between doctors and government there is discontent and resentment. The politicians remain convinced that they and the bureaucracy know best, that money - "the economy" - is the ultimate measure of sound policy. That fundamental old maxim that efficient government is only possible with the consent of the governed has been forgotten or discarded.
1. Sir Earle Page, Truant Surgeon , The Inside Story Of Forty Years Of Australian Political Life, Angus & Robertson, 1963. p. 379
2. Palmer & Short, Health Care & Public Policy - An Australian Analysis, Macmillan Education Australia Pty. Ltd,. 2nd Edition. 1994. pp. 60-61.
3. R.B.Scotton & C.R.Macdonald, The Making Of Medibank. School of Health Services Management, University of NSW , 1993. p.19.
4. Gough Whitlam. Abiding Interests University of Queensland Press. 1997. p. 223.
5. Commonwealth Committee of Enquiry into Health Insurance, Report, 1969
6. Gough Whitlam. Abiding Interests University of Queensland Press. 1997. p. 223
7. ALP Federal Conference, Launceston, 1971.
8 NSW Branch Australian Medical Association Monthly Bulletin, March 1969, p.3.
9. NAMS Steering Committee Newsletter, April 1972.
10. The Australian Health Insurance Program, (White Paper) AGPS, 1973.
11. NAMS New South Wales Newsletter No. 1, August 1974.
12. NAMS Bulletin No.l, May 1973.
13. Gough Whitlam. The Whitlam Government 1972-1975 Viking Penguin Books Australia 1985 p. 347.
14. Health Insurance Act (1973 No. 42 of 1974 ) Section 30 Commonwealth / State Agreement.
15. Gough Whitlam. The Whitlam Government 1972-1975 Viking Penguin Books Australia 1985.
16. R.B.Scotton & C.R.Macdonald, The Making Of Medibank. op. cit. pp.62, 159, 172.
17. Bill Hayden. Hayden An Autobiography. Angus & Robertson 1996 p. 198
18. House of Representatives, 18 May !976 (Hansard)
19 R.B.Scotton & C.R.Macdonald, The Making Of Medibank. op. cit. pp. 242- 249
20. Federal Court of Australia (NSW District Registry) No. G105 of 1978
21. Health Insurance Amendment Act 1984 (No.15 of 1984) Section 17
22. L.J.Opit, R.McK.F.Southby, Medical Specialist Practitioners in Australia: Present Indicatives, Future Trends and Consequences. Dept. of Social & Preventive Medicine, Monash Medical School, 1978.