COMMONWEALTH OF AUSTRALIA
DEPARTMENT OF HEALTH
CUSTOMS HOUSE, SYDNEY
14th August 1930
Dear Sir,
Adverting to your letter of 23rd July relative to the suggestion that the Commonwealth should assist in the appointment of a Medical Officer at Burketown, Northern Queensland, I submit herewith a possible solution of the difficulty.
As a preliminary I suggest that this matter should be considered in conjunction with my various proposals submitted from time to time for coordinating Medical Services in the Territory and adjoining parts of Queensland and Western Australia. In my opinion a necessary preliminary to consideration of the matter should be agreement between Commonwealth and State upon the following points.
- That the exigencies of Medical Service in these districts demand the provision of Medical Officers of a high professional standard who have been specially trained, experienced in the treatment and prophylaxis of diseases occurring in the districts, who have instructed in the requirements of Hygiene administration peculiar to districts with a preponderating Aboriginal population and whose activities are coordinated by an authority kept in constant touch with all phases of Medical Service throughout this region.
- That medical attention for residents in this region should be the best procurable and given at as reasonable a figure as possible so that:
- The Medical Officer will be kept reasonably busy;
- Disease will be treated early;
- Full opportunity will offer for the further study of diseases affecting the white man in Tropical Australia;
- Residents in these remote parts of Australia will receive the best medical attention procurable on terms within their means.
- The importance of Hygiene as a factor in successful settlement must be recognised. The eradication of endemic and the limitation of epidemic disease, the study of the effect of environment, climate and diet upon the white settler, particularly the school child, the care of the new born and the provision of proper maternity attention are all necessary public health utilities even in these remote localities:
- To preserve the maximum of existing settlement;
- To encourage immigration of white women thereby promoting increased settlement and stability, and eliminating those factors of deterioration consequent upon intimacy between white and Aboriginal.
If agreement be reached upon these points it remains to determine the most satisfactory method of achievement.
- Specially qualified Medical Officers: It would not be practicable to provide individually for every centre in this region, a Medical Officer who had received special training in tropical or State Medicine in addition to adequate experience in general medicine and surgery. Even if this were accomplished, unless the activities of each were constantly subject to co-ordination by a controlling authority, individual effort would yield little advancement, the valuable experience in one centre would not be available for another, and in any one centre change of officer would entail the loss even to that centre of all results of previous experience.
It is suggested that the Territory’s practice affords the best procedure. Competent Medical Officers are selected on offer of an adequate salary. These officers are trained in the special features of the Territory Medical Service before appointment to a rural station. Subsequent to transfer to a rural station they are subject to instruction, guidance and correction from the Administration centre at Darwin. This way they may quickly orientate themselves in the concerted plan whilst the central authority becomes fully informed of the varying conditions in individual districts and is therefore able to ensure continuity of policy and advancement with every change, of officer.
- Economy and Efficiency of service: It is becoming universal experience that the voluntary system of hospital maintenance is inequitable, uneconomic and unreliable. Various methods of ensuring stability have been tried without uniform success. In almost every instance the burden of maintenance of impoverished hospitals fells upon the Government which for motives of settlement policy endeavours often at considerable expense to keep hospitals open in these remote regions.
The policy of the Territory has been that the maintenance of Hospitals on a charity basis supplemented by a disproportionate Government subsidy is in a high degree unsatisfactory, and the Darwin Hospital is established as a purely Government activity. The Territory further found that the irrational appointment of part time Medical Officers in receipt of a subsidy and the right of private practice led to deplorable inefficiency.
- Medical Officers of good calibre were difficult to attract or impossible to retain owing to the necessarily low guaranteed salary (as represented by the subsidy) and the uncertain and unreliable complementary income from Private Practice.
- The Pubic were exposed to charges of an exceedingly heavy nature necessitated by the Medical Officer’s desire to supplement his subsidy often for services wholly out of proportion to the charge. This meant that often medical aid was not sought when really necessary, or the Medical Officer was not paid, both causes of friction.
- Important Medical and Hygiene service due to the government and assumed to be paid for by the subsidy was neglected when it conflicted with private practice. A tendency to regard this as logical and inevitable developed in both parties.
- In times of economic stress sufferers from malaria and other endemic diseases did not seek medical attention early so that their own lives were jeopardized and the control of dissemination was made impossible.
In the Territory it was decided to overcome these objections by appointing Medical Officers at guaranteed minimum salary adequate to attract good men, to forbid the collection of fees except for surgical operations and midwifery and to require Medical Officer to be whole time sub-ordinates of the Chief Medical Officer at headquarters. The public was thus protected from immoderate fees, particularly in the matter of mileage, a very serious matter in these regions, for the Government was in a position according to its policy to give all services wholly free, or to limit fees to an amount sufficient to reimburse all or part of the expenses incurred.
The policy in the Territory has been to organise the community into a Medical Benefit Fund entitling subscribers to free medical attention and hospitalisation etc., revenue being utilized as reimbursement of expenses of maintaining hospitals, paying salaries, and it is estimated that if the whole community is enrolled the service will be practically self supporting. This is an eminently more satisfactory system than that prevailing in any of the States, and is particularly suitable for the sparsely populated and ill served Districts under consideration. The Government at the same time is assured of proper coordinated effort in Public Health Service, and is assured of receiving a proper return for the unrecovered proportion of salary.
- The provision of a service on these lines renders the Administration of Public Health utilities and hygiene as outlined in sub-paragraph 3 above a matter of extreme simplicity and is indeed the only system upon which such administration can be conducted with the maximum efficiency.
The particular application of this principle to the Burketown Districts could be effected by organising the local population into a Medical Benefit Fund and devoting the revenue thus raised to the maintenance of the local Hospital and the reimbursement of Government for the salary of an experienced Medical Officer made available by the North Australia Medical Service.
Finance: The adult male population of the Burketown District is given as about 210 of whom 140 are unmarried and 70 married. On the basis of the subscription rate prevailing in the Territory the enrolment of the white population in such a Fund would yield revenue at the rate of £910 per annum. During 1929 the Queensland Government subsidised Burketown Hospital to the extent of £750 and paid the Medical Officer a salary of £25 per annum personally. The total Revenue available therefore might be expected to approximate £1,700 without additional maintenance expense being incurred by Government. The total cost of maintenance of Burketown Hospital last year exclusive of Medical Officer’s salary was £840. The salary of a Medical Officer in the North Australia Medical Service with car allowance, during the first year i.e. £950 per annum so that a expenditure of £1,790 per annum is required to maintain a Medical Officer and the Hospital, on last year’s basis. It is suggested therefore that:
- The local population agree to raise £950 per annum by organising a Medical Benefit Fund entitling subscribers to free hospitalisation and medical attention, and by the usual adjuvants to revenue raising indulged by Hospital Committees and for fees collected from non-enrolled persons.
- That the State of Queensland in the interests of policy and having regard to the improved service to be made available to the local white population and the 500 Aboriginals in the District raise the amount of its annual subsidy to a standard £800.
- That the Commonwealth provide the Medical Officer on the understanding that its financial liability during the first year be limited to £100 it being understood that the Medical Officer shall he available for the inspection and treatment of Aboriginals on the Territory side of the border and may be required to visit Borroloola and Groote Is. at least once during the year, the Medical Officer at Camooweal (who should also be an officer of North Australia Medical Service) attending to urgent work in the Burketown District during his absence which should not exceed 3 weeks. The cost to the Commonwealth may be expected to be recovered by the extension of the Medical Benefit Fund to the Borroloola District, and from the Aboriginal Medical Fund subscription to which will be compulsory upon all holders of licensee to employ Aboriginals in country districts. This of itself will place the Administration under some degree of obligation to provide Medical Services in these districts.
The total revenue should then approximate £1,800 per annum which by the practice of economical purchasing may he made to provide a small margin in case of increased activity or failure of the local population to reach its quota.
After the first year’s experience it may be necessary to readjust the proportions paid by the Governments of Queensland and the Commonwealth in the light of the value of services rendered. It is thought however that meantime the above proposal constitutes the most satisfactory basis for a test year.
It is to be noted that the extent of Queensland and Commonwealth Government subsidy is determined upon the basis of the provision of a Medical Officer specially qualified by reason of his being an officer of the North Australia Medical Service from which fact the local population itself must be expected to benefit both directly and indirectly. Any effort therefore on the part of the local committee to assert a right of control on this officer by reason of the increased proportion of cost which they would appear to provide must be resisted by the Governments. The word “appear” is used advisedly for the increased subscription from the local population is largely made up on what would originally have been paid as fees to a Medical practitioner in a capacity wholly outside the control of the population.
It may be objected by the Queensland Government that if the Burketown community is unable to raise its quota of £900 the deficit will have to be found by the State Treasury. It should be remembered, however, that the Queensland subsidy is founded upon £2 to £1 basis. If under the old system Burketown could raise £375 of subsidisable income, it should be able to raise £900 under the new. Ordinarily if £800 were raised the Government subsidy should be £1,600 whereas under this system only £900 would be required. It may be argued therefore that the Queensland Treasury is well protected by the agreement suggested.
Finally it is recommended that every effort be made to induce the Queensland Government to endorse these principles of organisation which though apparently entailing a small increase of expenditure at a time when the financial position is acute may be expected to yield a much more valuable return per Pound of outlay than does the system at present existing but which also may be regarded as entailing a definite saving in that:
- By providing adequate service locally it to a great extent obviates the necessity of costly supplementary provision in the way of aerial Medical services;
- By facilitating occasional transfers of Medical Officers without loss of status or salary and without prejudicing the efficiency of the local service it ensures permanently satisfactory staffing such as could not formerly be expected when Officers either remained indefinitely to deteriorate or left at short intervals in order to avoid deterioration.
Yours faithfully,
Cecil Cook
Chief Medical Officer
North Australia.
To: The Secretary,
Department of Home Affairs,
CANBERRA F.C.T.