Health Care (Private Day Procedure Centres) Amendment Bill

Second Reading

Adjourned debate on second reading.

(Continued from 21 June 2017.)

Mr KNOLL (Schubert) (17:03): I indicate that I am the lead speaker on this bill. I rise to make a contribution to the Health Care (Private Day Procedure Centres) Amendment Bill 2017. Not wanting, Winston Peters style, to hold out the suspense, I will say that we will be letting the bill go through this house—not that we have much other choice—but we will be seeking some assurances between the houses to discuss this matter further.

The bill seeks to amend the Health Care (Miscellaneous) Amendment Act 2016 to remove the requirement for facilities performing procedures under local anaesthesia to be licensed as part of the Health Care (Private Day Procedures Centres) Amendment Bill 2017. The bill regulates stand-alone private day procedure centres through various licensing arrangements and the setting of standards for construction, facilities and equipment.

The minister for health, the member for Playford, clearly stated when he tabled the 2016 bill that the government intended that some local anaesthesia procedures would be regulated. The Australian Nursing and Midwifery Federation and the Australian Day Hospital Association proposed that local anaesthesia be included in the act rather than the regulations, as proposed by the government. On 17 May 2016, the Legislative Council supported opposition amendments which brought local anaesthesia services into the act.

The government drafted and put a related amendment that included local anaesthesia whilst exempting health services provided by a medical or dental practitioner in the course of general practice. The bill passed both houses, including the lower house where the government has the numbers, and covers the following scope of services. A prescribed health service is:

(a) a health service that involves the administration of general, spinal, epidural or major regional block anaesthetic; or

(b) a health service that involves intravenous sedation (other than conscious sedation); or—

and this is the operative clause—

(c) a health service that involves the administration of local anaesthetic; or

(d) a health service, or health service of a class, prescribed by the regulations for the purposes of this definition.

In the second subsection:

Paragraph (c) of the definition of prescribed health service does not apply in relation to the following health services involving the administration of local anaesthetic:

(a) a health service provided by a medical practitioner in the course of practice as a general practitioner;

(b) a health service provided by a dentist in the course of general dentistry practice;

(c) a health service, or health service of a kind, prescribed by the regulations.

The 2016 bill, which references local anaesthesia, has not been proclaimed. In June 2017, the government introduced the Health Care (Private Day Procedure Centres) Amendment Bill 2017, which would remove reference to local anaesthesia from the bill. The government claims that the amendment is necessary because of a concern in the medical community that the act would prohibit specialists and other practitioners from performing routine surgical procedures in their private medical consulting rooms or office-based surgeries without being licensed as a private day procedure centre.

I understand that the government considers that all relevant local anaesthesia procedures should be brought within the scope by a regulation under paragraph (d) but, if this bill passes, the act itself would not regulate local anaesthesia. Currently, several day hospitals only provide services under local anaesthesia. New local anaesthesia-only hospitals will continue without regulation if this amendment goes through. In early September, another death occurred in a clinic in Sydney from breast surgery under local anaesthesia.

Day Hospitals Australia, the body representing day hospitals, considers that the act should cover facilities providing procedures under local anaesthesia because, firstly, many procedures performed under local anaesthesia should be undertaken in an operating environment to reduce risks of complications such as infection, anaphylactic shock and excessive bleeding. Secondly, private health insurance funds may refuse to fund procedures performed in a day hospital setting under local anaesthesia on the ground that such procedures are not required to be performed in licensed premises.

I understand that the Australian Medical Association and the Australian and New Zealand College of Anaesthetists consider that compliance with ANZCA guidelines and other patient safety issues should be addressed in the regulations by listing relevant procedures that, if done under local anaesthesia, need to be done in a licensed facility. Day Hospitals Australia is concerned that such a list would take time to develop and has the potential to change considerably with new and advanced surgical techniques allowing more and more procedures to be undertaken under local anaesthesia.

Day Hospitals Australia suggests that procedures that require a hospital setting could be better defined using Type B and Certified Type C procedures defined under the rules of the Private Health Insurance Act 2007. Any procedures falling outside this classification would not be funded by private health insurance and would most likely be performed in medical practitioners' rooms.

I am handling this bill in this house on behalf of the shadow minister for health, as the Minister Assisting the Minister for Health is undertaking this for the government in this house. As I understand it, we would all like to get to the same outcome, but there is a disagreement legislatively about how this is best achieved. I will attempt to unpack it in my layperson's understanding with the hope that we can get some clarity as we go through the committee stage of the bill so that, in the other place, any of these so-called disagreements and so-called misconceptions can be cleaned up.

As I understand it, if we pass this amendment, local anaesthesia-only practices will not be regulated. That makes sense, and in fact in the 2016 bill that is why a section was made for local medical practices as well as for dentistry. There is a set of people who only do local anaesthetic in surgeries and private centres. We then have a situation, though, where we have day hospitals that undertake local as well as general anaesthesia. They undertake both types of procedures.

The crux of the matter comes down to putting in local anaesthesia as part of the act. The understanding is that all day hospitals be regulated, whether they undertake general or local. If you have day hospitals that are undertaking general and local, and local is not included as part of the act, the local procedures that I am going to call a 'hybrid' day hospital provides will not be regulated, and that may cause some issues in terms of insurance companies funding those procedures, but also we could have day hospitals that undertake local-only procedures also not being regulated. The idea behind putting it in the act is to make sure that those two situations are covered.

I understand that what we are trying to capture here is that day hospitals are regulated no matter what they do, and I assume that that is because they undertake more serious types of surgeries and different types of procedures. We are essentially trying not to put a regulatory burden upon more simple, basic procedures in relation to dentistry, medical practitioner and, as has been put in the second reading explanation, certain types of cosmetic surgery.

The question for me becomes: why not, as we have done with dentistry and general practice, create a broader set of exemptions for those that we seek not to be regulated for their local anaesthetic procedures? Why is that not an acceptable answer? I do accept the argument that this is an evolving space, and if we are going to have to get to the point of regulating procedure by procedure through the regulations we are asking the government of the day to be able to keep up with changes to medical advances. We in the opposition are genuinely trying to come to the best understanding of what legislative requirement achieves that outcome so that everybody that should be regulated is regulated but everybody that should not is not.

I think it is a genuine disagreement, and I think that the interjections from the former minister for health earlier are a bit unfair because we are trying to get to the right outcome, and essentially there are two competing sets of advice. In the committee stage, we would like to see (not necessarily today but between the houses) if there are any draft regulations that have been put together so that we can make an assessment, if I am correct in what I have just said, of whether or not that is what is achieved by passing this amendment bill, as it is in conjunction with those regulations, and seek an assurance that local anaesthetic procedures in any day hospital, whether they be centres that provide both general and local or local only, are all covered.

It is interesting when an association comes and says, 'No, we want to be to regulated and we need to be regulated because we believe that that lowers the risk we have with insurance companies paying for these procedures.' I think that that is a legitimate concern to raise. I think that if we can actually come to an understanding about what I think is the central conflict in this amendment bill, we can actually reach a workable conclusion.

I sit next to the deputy leader, who this week and many other weeks has to come into this place as the government furiously comes in because they need a piece of legislation to fix a previous piece of legislation which they passed and it all needs to be done quite urgently because they have made mistakes and they are a bit red-faced. We would prefer to get it right, and that is why we will be seeking the assurances that we are to ensure that we can get a decent outcome and get back to what we essentially are trying to do, that is, to balance over-regulation and under-regulation with patient safety and ensure that we find the most appropriate way forward.

Mr SNELLING (Playford) (17:15): It is very gallant of the member for Schubert to come in here and defend the indefensible. I hope that the Hon. Stephen Wade, when he speaks to this bill in another place, at least has the decency to admit his error and stupidity in moving an amendment to a bill that would have had the effect on GPs who provide local anaesthetic to put in stitches—and not just GPs; specialists as well do minor procedures in their rooms and administer local anaesthetic—of banning those practices or at least forcing medical practitioners to become licensed day procedure sites in order to do those procedures, which is just absurd.

The original intention of this bill was to bring into the scope of state regulation day procedure facilities. This is effectively facilities which, for all intents and purposes, operate as a hospital but do not have inpatient beds. They are there for day procedures, so people come in the morning. With the increase in day surgery, we have seen a number of these sites established where they do not have the opportunity for patient stay overnight, to be admitted as an inpatient. They are effectively seen and discharged the same day.

Previously, those day procedure sites had to be licensed by the federal government. The existing state legislation did not cover those day procedure centres. The purpose of the original bill was to bring those centres under the scope of state regulation so that they could be appropriately licensed in exactly the same way that private hospitals are licensed. In the other place, the Hon. Stephen Wade, trying to be clever, decided to move an amendment, which passed through the other place, which would have had the effect, as I said, of bringing into scope not only the day procedure centres the government was seeking to regulate but, in fact, any GP clinic where the GP used local anaesthetic as a fairly routine matter.

The effect that would have had on our emergency departments and people just needing a couple of stitches not being able to be done in the rooms of a GP, or people needing to have a mole removed or anything like that, which can all be done safely and appropriately either by a GP or sometimes a specialist in their rooms, would have meant those things would have been brought into the scope of the act, which was never ever the government's intention.

I remember the outrage from the Australian Medical Association and the specialist colleges who wrote to me absolutely appalled, and I took no pleasure in directing them to the office of the Hon. Stephen Wade, who had sponsored the amendment. So let there be no doubt that the reason we are here is to clean up the Hon. Stephen Wade's mess. Should he ever occupy the office of health minister, if this tells us what to expect from a Wade health minister, then God help us if he makes such bumbling mistakes on something so straightforward. All he was seeking to do was try to score a cheap political point and it blew up in his face.

The Hon. C.J. PICTON (Kaurna—Minister for Police, Minister for Correctional Services, Minister for Emergency Services, Minister for Road Safety, Minister Assisting the Minister for Health, Minister Assisting the Minister for Mental Health and Substance Abuse) (17:20): I thank the speakers on the bill, particularly the member for Playford and the member for Schubert. I have to say that I dare to agree with the member for Playford's comments more than the member for Schubert's comments.

I do appreciate the extent to which the member for Schubert went to try to explain away the problems with the shadow minister for health, Stephen Wade's stuff-up that led to our having to bring the bill in, as though there are some sort of deep public policy issues at stake here and that there are all sorts of technological things in the future that we need to consider, rather than the fact that this was just an absolute stuff-up by Stephen Wade and something that, regretfully, we have had to come back to the house to try to fix up.

You just have to talk to any of the key health bodies to understand how problematic this amendment by Stephen Wade would have been to the provision of health services across South Australia. I will read a letter that we have received from the Australian Medical Association outlining their very strong concerns about what was put in place by Stephen Wade in the other place in terms of the bill. It states:

The Australian Medical Association… is greatly concerned and disappointed over the amendment to the Health Care (Miscellaneous) Act 2016 and specifically part 10A—Private day procedures centre, s89(1) and s89(2)(a).

The above amendments to the Health Care Act… have led to overwhelming uncertainty and anxiety amongst our medical specialist members and the wider medical community. The amendment places a significant number of diagnostic and treatment services currently conducted safely, for and on behalf of the public of South Australia, at significant risk.

Our main concern is the effect of Part 10A, which states 'local anaesthetic' is included as a 'prescribed health service' for the purposes of licensing of stand-alone private day procedure centres, meaning that outside of general practice and dentistry, ALL services provided by specialists requiring a local anaesthetic will need to be performed in one of the soon to be licensed private day procedure centres.

Whilst the AMA(SA) appreciates the reasoning behind seeking to introduce a licensing framework for such centres, it is reprehensible that the broad effect of this legislation, due to commence on 1 July 2017, will severely restrict the practice of all specialists who undertake to perform minor surgical procedures outside of a private day procedure facility.

Public access to a wide range of specialist services including, but not limited to urology; gynaecology; dermatology; pathology; radiology; plastic and reconstructive surgery; ophthalmology and others will be significantly reduced.

The public inconvenience and outcry caused by this restricted access will be significant. The increased service costs due to the unnecessary but mandated (under the new provision), infrastructure service requirements will be burdensome. Patient costs for minor procedures will be increased and delays in diagnosis and treatment unacceptably lengthened. In addition there will be flow-on effects to the public health sector.

To further highlight the discriminatory impact, general practitioners and dentists are excluded within the new amendments! We believe this anomaly must be the result of oversight, as it cannot be made on any credible grounds of public safety.

The above is totally unacceptable to the AMA(SA) and we seek an urgent review of this disruptive and carelessly drafted legislative change.

You could not get a more damning indictment on the provisions in legislation, of the drafting of provisions that have gone into a bill, than the AMA has given in this letter against what Stephen Wade put in the Health Care Act. It is absolutely shocking that somebody would put into legislation something so poorly thought through without considering what ramifications there were going to be down the line in terms of our healthcare provisions. It is something that we have had to change in terms of what we bring here today. Unfortunately, I think that it is something that if it had been sorted out in the beginning, we would not have to have spent the parliament's time on. I hope that this is something that the opposition will see as important to fix both in this place and the other place. I endorse the bill to the house.

Bill read a second time.

Committee Stage

In committee.

Clause 1.

Mr KNOLL: As I said in my second reading contribution, I think there is a central disagreement here, but I find the sanctimony of those opposite galling because they voted for it in this chamber. If you guys thought—

The CHAIR: Do you have a question on the bill?

Mr KNOLL: If you guys thought that this was a problem, why didn't you amend it? Do not come in here and get all sanctimonious—

The CHAIR: Member for Schubert, order! Do you have a question?

Mr KNOLL: I do.

The CHAIR: What is the question, member for Schubert?

Mr KNOLL: Does the government have a draft set of regulations in place in relation to this amendment?

The Hon. C.J. PICTON: The government has drafted regulations to be under the new act. In fact, it was in the process of consulting with the medical profession on the drafting of those regulations, in which bodies like the AMA and a whole range of other medical bodies came to us and said what their significant, fundamental problems were with the proposed changes that were put in place by the Hon. Stephen Wade.

After the passage of this act, hopefully, we will go back and have another look at the draft regulations that we have proposed to see whether there needs to be any changes to them. Draft regulations were provided and publicly circulated, and we are happy to share them with the opposition.

Mr KNOLL: If this amendment goes through, will day hospital centres that only conduct local anaesthesia procedures be covered by this?

The Hon. C.J. PICTON: I understand that existing day hospital procedures that have a provider number will be deemed to fall within the prescribed class under the act, to happen from 1 May next year.

Mr KNOLL: For those day hospital centres that undertake both local and general, will the local procedures that they perform be covered if this bill passes?

The Hon. C.J. PICTON: The idea is that this is about prescribing the centre. So if you are a prescribed centre, the activities that take place in that centre are prescribed. The issue is that the scope of what was being proposed by the Hon. Stephen Wade was so broad that it would suck up all the times in which local anaesthetics were used in the community in a whole range of different clinical settings, in a whole range of different consulting rooms and, as I understand, even to the extent of areas like podiatry, etc. They would fall under this as well.

In regard to actual day procedure centres, their activities are covered in terms of the fact that they are operating under this section as prescribed centres. We are proposing that other people who just provide local anaesthetic should not have to be under the burden of excessive red tape that the original provision would have had.

Mr KNOLL: How many centres are likely to be covered by this legislation?

The Hon. C.J. PICTON: There are 32 private day procedure centres that have provider numbers and they will automatically be deemed to be covered under the legislation.

Mr KNOLL: How many of those use predominantly local anaesthesia?

The Hon. C.J. PICTON: I understand that about five or six of those 32 would predominantly use local anaesthetics.

Mr KNOLL: If this bill is passed, what will the next steps of the implementation plan be?

The Hon. C.J. PICTON: After this is passed, we will go back to working on the regulations, which was a process that had to be stopped while we brought this back to the parliament and then continue to implement it after that.

Mr KNOLL: Is there a firmer time line than that?

The Hon. C.J. PICTON: We have to try to get everything in place by 1 May. That is the time line that the SA Health people will be working towards

Clause passed.

Remaining clauses (2 to 7) and title passed.

Bill reported without amendment.

Third Reading

The Hon. C.J. PICTON (Kaurna—Minister for Police, Minister for Correctional Services, Minister for Emergency Services, Minister for Road Safety, Minister Assisting the Minister for Health, Minister Assisting the Minister for Mental Health and Substance Abuse) (17:31): I move:

That this bill be now read a third time.

Bill read a third time and passed.