Bills

Health Care (Governance) (No 2) Amendment Bill

Second Reading

Adjourned debate on second reading (resumed on motion).

Mr PICTON (Kaurna) (15:37): I delight in continuing my contribution on this important matter of the Health Care (Governance) (No 2) Amendment Bill 2019. Before the break, I was talking about what is happening at the moment in the governance of the Central Adelaide Local Health Network where the government has appointed, in a completely unprecedented way, two administrators from an external consulting company, a corporate liquidation company—KordaMentha—to be public servants of that organisation.

This is a contract and a process that has so far cost taxpayers at least $23 million, and that only runs for the next few months. After that, it will be substantially more. We have seen so little evidence of any benefit whatsoever out of this process, except for the people who work for KordaMentha who are getting the profits out of this arrangement to the point where, as I spelled out before lunch, we saw in the most recent budget a $282 million blowout in the health budget over the past year.

It is pretty incredible how ineffectual this process has been, despite how unusual it is and despite how many questions there are about the procurement of how this was entered into and how it is going to be running now. Ultimately, we do know from the report that was delivered by KordaMentha in their first contract with the government for some $880,000 that they propose to cut very significantly into our health services, particularly at two hospitals, the Royal Adelaide Hospital and The Queen Elizabeth Hospital, where they are proposing to cut over 170 beds.

They outline very clearly in the report how many daily bed nights will need to be lost, which works out that every single night over 170 beds would have to close at those hospitals. We also know, because it is spelt out in the report, that they are projecting to significantly reduce the activity of those hospitals, and they are looking at reducing what is called equisep, which is a measure of activity of hospitals, by the equivalent of about 3,500 hip operations, so a very substantial reduction in operations would happen under the plan.

The proposal they put forward was to cut some $460 million over three years. In the first year of that, only $40 million was going to be cut, which means that some $420 million has to be cut over the next two years at the Central Adelaide Local Health Network to meet these savings tasks the government has set through this administration. That is a very significant reduction. At the same time, we clearly have at the moment some very significant demand on our hospitals. We have overcrowding basically every single day.

We have Code Whites happening in in our emergency departments every single day. We have ramping happening every single day in our hospitals. To cut staff, to cut beds and to cut operations while we are seeing this unprecedented flu season, at this time of the year, and while we are seeing very unprecedented ramping happening in our health system is just a recipe for disaster. That is a very significant concern about what is going on in the governance of that local health network.

Before the break, I was talking about the consultation that occurred in relation to the first piece of legislation the government presented to us, where they did not really consult at all. In fact, we were leading the consultation by talking to people after the bill had been submitted to the parliament, and they had not seen the details of the bill at all. This time around, the government said that they were going to try to do things differently. They said that they were going to consult with people and, in fact, they did send out the draft bill for people's comment, but they gave people only a very limited amount of time to do it.

In fact, they introduced the legislation into the other place the day after the stakeholder feedback ended. The closing date for the feedback from all those organisations was one day prior to the bill being introduced. I am sure that anybody who is familiar with the processes of government would realise that between receiving stakeholder consultations and introducing a bill, if you are going to take the process seriously you need a lot more than 24 hours to do it.

You cannot seriously have people believe that within the space of 24 hours the minister and the department read and considered all the stakeholder submissions they received, sought advice on all the submissions they received, made amendments through parliamentary counsel to the legislation, as was required, based on their understanding of those submissions they received, went through the cabinet process within that 24 hours, went through the party room process within that 24 hours and had it introduced all within 24 hours. It is absolutely impossible for that to happen.

No doubt what actually happened was that we had the stakeholder submissions closing just so that they could say, 'We did some stakeholder consultation.' None of those comments at all were considered before the bill was introduced into the parliament because there was simply not time to do that within that day. It is pretty clear that a whole range of comments were raised by people during the consultation that were not incorporated into what was ultimately presented to the other place. We know because those people have told us, and we know that because we have seen some of the stakeholder submissions that were made on the draft legislation, and it is pretty clear that people were unhappy in a lot of ways about the legislation.

Some of those ways we, with the crossbench, have sought to remedy in the other place, and we have been successful in doing so by amendments we brought forward to the legislation that was presented originally by the Minister for Health, but in other ways there are still a lot of issues that need to be resolved in how that works. I will soon go through some of those submissions we received, and submissions the minister in fact received, about those issues. I want to clear up a few other things about the bill before going through those submissions in detail.

One of the issues that we have been particularly concerned about is the engagement of consumers in our health system. We need a health system that properly engages consumers and patients. Something that has been recognised for at least the last two decades is that we need to improve patient-orientated healthcare provision. To do that, we need to listen to the patients and the consumers of those services. To do that properly, we need to empower those people to speak up, train them to do so and create advocates for the consumers of those particular health services.

There will always be very strong voices in the health system coming from particular employment groups, there will always be a very strong voice for doctors, there will always be a very strong voice for nurses and there will always be a very strong voice for paramedics and other groups, but it does need support to make sure that there is a very strong voice for patients. That is why the previous government, very early on in the term of the Rann government, created and helped establish the Health Consumers Alliance of South Australia.

It was to be an independent organisation, separate from government but supported by government through peak body funding, that would advocate on behalf of consumers and patients in the healthcare system, that would train those consumer and patient advocates to represent them and take steps, as required, to be involved in discussions, planning and consultation right the way through the health system to make sure that at every stage of those discussions and developments consumers are at the table and have a voice, as do all those other groups. That is what the Health Consumers Alliance has been doing for the last 16 years.

Sadly, what we saw in the last budget was that all that funding was cut. The entire funding for the Health Consumers Alliance was cut—not 50 per cent, not 70 per cent but 100 per cent of their funding was cut. The government is saying, 'We don't need that because we've got these boards now,' even though the boards basically have no representatives of consumers on them at all—one or two maybe, but hardly what they were promising people.

This is an organisation that is needed but, because of this budget cut, they have had to make very significant cuts to their staff and they have had to get rid of their office. They are working in a co-sharing space at the moment, which is hardly ideal for training consumers and dealing with sensitive issues and experiences that patients have had in the healthcare system. They have had to remove most of their staff who were doing that. They are basically hanging on by a thread to their existence.

One of the things that the other place insisted upon as part of this legislation is that we should have a voice for consumers and that it should be mandated that the government should have to support such a voice. If we could have legislated in such a way as to say that the government should restore that funding they cut from the Health Consumers Alliance, then we would have done so. Clearly, within the powers and vestiges of the upper house, they did that in the best way possible in making clear that one of the roles of the chief executive is to make sure that there is an organisation that supports consumers in the health system—i.e., to make sure that an organisation such as the Health Consumers Alliance is in existence and continues to play the very important role of representing patients and consumers in the health system.

One of the great worries we have is that this government, bit by bit, is trampling those voices that sit across the whole health system and provide guidance and independence for the entire health system. They want to get rid of the Health Performance Council. They want to gut the Mental Health Commission. They are basically setting up the Health Consumers Alliance to close down. This is all very different from the hallmarks of transparency that the now government talked about when they were in opposition. It is a complete 180° turnaround from their so-called promises back then and it is very disappointing.

There are a few other issues that are emerging, one of which is that the government set these boards up and has said that one of the reasons for doing that is to give people in regional communities a strong voice, independent of government, about their health services. But, lo and behold, one thing that the government has done is that they have slipped in a charter for these boards and how they are to operate that says very clearly that board members are not to say anything, that board members are not to speak in the public discourse—in the media—about anything that is going on and that it should be through the chair.

It also says that board members have to be reminded that they speak for the department and for the minister. I thought these people were meant to be independent representatives of their community, but here we have this government document that sets out that they are speaking on behalf of the minister and need to be mindful of that. So which are they? Are they independent representatives of their community who are able to advocate or are they people who have to be pulled into line by the government? It seems that it is the latter.

It seems that, once again, this is a sort of Clayton's version of independent governance of the health system that the government is putting in. None of this was ever announced anywhere. Recently, it has just popped up on the governance page of the health department. I think that board members who went onto those boards thinking that they were going to represent their communities will be very disappointed to read that. Their communities, who were expecting that promise to be articulated and represented in the government, will be very disappointed with that outcome.

There are some very significant questions about how this system is going to work in terms of leadership, in terms of who is ultimately responsible for the running of the health system. So much of how this new structure is going to work is going to come down to the service level agreements. This was something that has been in the health system for some time, but is now going to have such added importance because of the inherent conflict between the minister and the department and those boards that it is all really going to come down to what is in this service level agreement.

It is going to be quite difficult for boards if they do not have a proper say in how that service level agreement should be articulated. What happens if there is a conflict is very unclear. What happens if there is a conflict between the Chief Executive of SA Health and a board about what should go in their service level agreement? What if the board says, 'Minister and department, you are not giving us enough funding to do all the things that you are telling us to do and we need a change to that agreement to say that we can't do that'? There is no mechanism in this legislation to solve that.

The answer from the minister and the department so far seems to be, 'We don't think it will come to that.' I think that is pretty significant. The minister's second reading speech in the other place had very little detail of what would happen in the event of a dispute between the Chief Executive of SA Health and the boards over funding, priorities or service level agreements. This is also an issue that has been raised by other groups in consultation.

Interestingly, the interim board chair, who is now the board chair of the Southern Adelaide Local Health Network, Mr Mark Butcher, appointed by the minister himself, wrote to the minister saying that there should be additional details surrounding service level agreements to specify the volume, scope and standard of service provided to a local health network. I think it is very telling that the government has chosen not to act on that advice by the local health network.

It is pretty clear that there is a disagreement between the boards and the government already about how that system is going to work, and there are significant concerns about that. There are also some big issues about who the employers of staff are. The minister promised this legislation months and months before it actually came into the parliament. He promised it would be passed well before July and here we are in July with it only recently being introduced into the house this week, if not the week before.

This is a big issue in terms of who is actually employing people. This has been a big issue of contention between the local health network boards, the minister and the department. Remember that the boards are in this unenviable position where they take all the blame for things but they do not set their budgets, control their staff or necessarily control their targets and service level agreements. They are saying, 'This is pretty bad. Why shouldn't we be in control of the staff who work in this agency?'

Likewise, a lot of the employee representatives say, 'We don't want to have a whole range of different employment local level agreements. We think that workers' rights should be protected across the board.' There is inherent conflict. We understand that this escalated to the point where the chairs of the boards got together and made a beeline—not to go and talk to the Minister for Health because, as anybody who studies the Marshall government knows, ministers are not really in charge of their portfolios. Who do they make a beeline for? The Treasurer, the Hon. Rob Lucas, because he is really running the government.

A crisis meeting was held between the chairs of the boards and the Hon. Rob Lucas, the Treasurer, to decide how this process was going to be decided. The Treasurer ultimately carried the day: these decisions would be held centrally. Yet again, this is another step by which this is not actually devolved. None of those 32,000-odd FTEs in SA Health, which is many more employees by headcount, report to their local boards: they all report to the Chief Executive of SA Health, just as they did before this legislation came in.

There is no change to the staffing arrangements at all in terms of who is ultimately responsible. It puts the boards in an awkward position where they are responsible for what happens in their hospitals but not responsible for who works there and provides all the services, which I think is going to be very odd in terms of how that actually works.

Over the past almost 16 months, we have seen the impact of the Marshall government on our hospitals. While we have corporate liquidators running around earning big bucks, we have hospital beds closing. While we have board directors being paid $15 million over four years, we have record ramping. Ramping is now more than double, every day, every month, what it was back when we were in government—more than double. There are now more than 2,000 hours when ambulances are delayed, stuck at emergency departments, waiting to offload patients.

That is time when they could be out helping other patients. That is time when they are not on the road, responding to call-outs. Ultimately, that means that in the past year we have seen some very significant declines in response times for ambulances, which is of very significant concern. That situation is only getting worse and worse. Every week now, we see ramping at extraordinary levels in South Australia, and there is no plan to do anything about it except to cut staff. In fact, they have now delayed important emergency department upgrades.

We put in place a plan for a $52 million upgrade of the Lyell McEwin Hospital, which is one of the fastest growing hospitals in our state given the fast growing population of the northern suburbs. That has now been pushed back a year by this government. They had said in their last budget that they would spend $12 million of that funding upgrading the hospital emergency department in the financial year that has just gone, the 2018-19 financial year. Well, they spent only $1.5 million of that. They have hardly turned a sod in the ground. Very little work has happened on that project. Meanwhile, we have very significant ramping happening across the health system.

At the same time, I think that there are very big questions about what will happen with SA Pathology, and that directly relates to the governance of the health system. The governance of the health system at the moment, both under the old system and the new system, is that statewide services such as SA Pathology, SA Dental Service, and Drug and Alcohol Services of South Australia (DASSA) reside within local health networks. They report to those local health networks, not centrally. That is now enshrined in the legislation that the government has passed.

It was one of those issues where they were umming and ahing about whether to change it but they have decided to keep that in place. I think what that creates here is the question: how is the privatisation that the government has mooted of SA Pathology going to happen? Is it going to be a decision by the government centrally? The way I read the legislation now, this would be a decision of the local health network. The local health network could decide to privatise SA Pathology because it is within their remit to do so.

Who is really in charge of that? We know that the current acting chief executive or acting executive director of SA Pathology is also the Deputy Chief Executive of the Department for Health and Wellbeing. This same person is responsible for a whole range of other things across the entire health system, including finances, human resources, communications—very significant responsibilities—and, I think, even procurement. They are massive responsibilities. But in her spare time, she is meant to be in charge of SA Pathology, which is much more than a full-time job in itself.

It also raises the question: when she is working for SA Pathology, who is she reporting to? Is she reporting to the Central Adelaide Local Health Network (CALHN) and reporting to their board, or is she reporting to the Department for Health and Wellbeing? I think there are big questions about how that is running in practice and who ultimately is responsible for those statewide services.

We have recently seen the government announce that they are going to cut 100 staff from SA Pathology, and that is just the beginning. The minister has outlined that it will potentially be up to 200 staff who will go from SA Pathology while the government is considering whether or not to privatise it. There is no way that that can happen, particularly with an increase in the number of patient tests that we have seen, without hitting South Australians in terms of the performance of those services, the delays in getting services, but also, very importantly for South Australia, the research and the teaching in our health system that are so important and where SA Pathology provides such an important role.

Unfortunately, we have seen some other very significant cuts come about which are going to impact upon the hospitals covered by this act. We have seen cuts to sexual health services. SHINE SA provides fantastic community health services. It had its budget slashed in the last budget and, ultimately, that has led to them having to close down two important centres, one in the northern suburbs and one in the southern suburbs. This is at the same time that we are seeing the rates of infection going up. At the same time that we should probably be seeing improvements in those services, we are seeing closures thanks to this government.

We saw the closure of an important HIV service in South Australia, Cheltenham House, due to 100 per cent of its funding being cut by the government. We have seen no winter plan from this government, just a website and a TV ad, and no additional resources going to help the situation. At the same time, we are stiffing nurses, cleaners and other hospital staff with $725 extra per year in car parking costs. We are stiffing patients, carers and loved ones with 20 per cent more car parking costs. We are also now jacking up the rates of getting an ambulance to over $1,000 for the first time, which is a massive impost for somebody, particularly on a low income, who needs emergency treatment. This is the record of this government and it is particularly disappointing.

I will run through a number of issues that have been raised by some of the stakeholders, particularly those who were consulted in terms of the legislation. There was consultation with the Health Performance Council, a body the government proposed to cut in its entirety. The minister received a letter from the chair of the Health Performance Council, Mr Steve Tully, which sets out in no uncertain terms his concerns over the legislation and his concerns in terms of the direction that the government was going in. He said:

The council sees many opportunities, and is working to contribute to your government's efforts to provide quality care for all South Australians. In its current form, this bill focuses too narrowly on public health services and a process perspective rather than a population-wide and whole health systems perspective. This will be to the detriment of understanding all-of-SA population health outcomes. A picture of health system performance that only draws on public hospital activity is incomplete and may be misleading.

In our role under our act, the council advises you on significant trends in the health status of South Australians and considers future priorities for the health systems in South Australia. This whole-of-system approach can identify movements in health outcomes, including trends that relate to particular illnesses or population groups, as well as reviewing the performance of the various health systems established within the state. For example, in the latest four-yearly report (December 2018) patient movement between the public and private health systems remains a huge data blind spot in South Australia, and oversight is important so that the SA population is adequately and safely served.

The Health Performance Council output has a distinct and strategic role that can authenticate and support service level agreement implementation. We offer a whole-system perspective with legitimate challenge to information aggregated under service level agreements, and tests this information by drawing on different sources of intelligence, quantitative and qualitative, most especially in forming advice about how to tackle disparities between outcomes for specific population groups.

The Health Performance Council has a practice of designing review projects with stakeholders and community, and works in favour of publication of our work to promote transparency. Aboriginal peoples' inclusion in the health performance process is intrinsic to the Health Performance Council way of working. For example, we proudly co-host Aboriginal Leaders' Forum…[with] SAHMRI, and I look forward to welcoming your visit to our next forum meeting…Aboriginal Leaders' Forum originated in the recognition that more was needed to deliver Aboriginal intelligence and sense-checking to health statistics and health service performance assessment as it reflected the reporting of Aboriginal population health and the design of policy and service improvement.

There you have a letter from the government's own independent council overseeing the health system, providing strategic advice, saying that this bill the minister drafted did not cut the mustard, did not provide a whole-of-system approach. It did not look at the whole continuum of health services, and abolishing the Health Performance Council was going to be not only a detriment to health care in South Australia but actually a detriment to the implementation of the minister's own supposed reforms themselves.

I mentioned before the issues around those service level agreements. The Health Performance Council have outlined how they can play an important role in making sure those health service agreements can be dealt with. One of the very important consultation documents we were presented with was a joint statement on behalf of a very significant number of health bodies in South Australia that were concerned about this legislation.

It was submitted to us, the government, and all the crossbenchers in the other place. They then followed up by having a consultation forum with all those bodies represented to talk through their issues with legislation and try to get improvements to them, many of which I am glad to say the upper house took heed of. I hope we do not see the government amending those back to the way the government originally wanted them here in this house.

Those bodies were quite varied and wide. We had the South Australian Council of Social Service (SACOSS), the Health Consumers Alliance, the Aboriginal Health Council, the Lived Experience Leadership and Advocacy Network, the Australian Association of Social Workers, the SA Network of Drug and Alcohol Services, the Australian Health Promotion Association, the Public Health Association, and the Mental Health Coalition. As part of the consultation session we had with all those bodies and all those parties represented in the parliament, the Australian Medical Association also took part and reflected a lot of these views as well.

They had a number of recommendations that needed to be addressed in terms of the legislation. Firstly, oversight and independent safeguarding bodies: retain the Health Performance Council as a mechanism for an independent line of accountability and therefore oppose clauses 4, 5, 7, 17, 18 and 22 of the government's bill. If the government want to replace the Health Performance Council with a new commission, they should come to the parliament with a bill to enshrine that commission, its powers, oversight, reporting and independence, before abolishing the HPC.

As I was saying before, we have this government saying they want to set up a commission, but there is no actual meat behind it, there is no legislation behind it, and there is no independence behind it. It is just going to be an office in the department, and all these bodies are saying, if you want to replace the Health Performance Council with that, you should legislate for it. You should actually design it and implement it with the blessing of the parliament and with reporting to the parliament.

They also recommended amending the acts to give consumers and those with lived experience an independent voice. This could be done by inserting into section 7 a requirement that the chief executive shall ensure a percentage, to be set by regulation, of a funding amount allocated to the LHNs through their service agreements is directed to an independent, non-government health consumer organisation for individual and systemic representation and advocacy and to ensure evidence-informed consumer and community engagement in healthcare services policy, planning and services.

As I was saying before, we have the Health Consumers Alliance that has been completely defunded by the government. Here we have a recommendation to try to bring that back through this legislation. Unfortunately, that could not be the case due to the Constitution Act, essentially, but what has passed through the other place is a provision that the chief executive should have to establish a process by which health consumers are represented and establish a body to do so, which I think is vitally important.

There was also a recommendation to statutorily enshrine the Mental Health Commissioner as an independent statutory body under the act with appropriate powers and independence. Enshrining that in the legislation, thankfully, is in here at the moment. I hope that the government does not amend it out because that is so important in making sure that body is not just going to continue to exist but is actually going to be independent and have the powers and resources that are needed. There was also a recommendation to amend the functions of the Health CE to include:

a focus on health promotion and primary health care, including in policy and practical programs;

ongoing engagement with external stakeholders and consumer representatives to inform and influence healthcare services policy, planning and services;

public reporting on the performance, population health outcomes and patient-reported outcome measures (PROMs) at a local level and systemic level to inform and influence services policy, planning and services; and

the ability to direct broad-based systemic change and specific programs and service.

There was a recommendation to amend the functions of the board in section 33(2) of the 2008 act to give LHNs more focus on health promotion and primary and Aboriginal health care in their local areas. The functions as drafted are currently very hospital based. The service agreements in clause 8 of this bill must be developed in consultation with community representatives and peak bodies and with reference to the applicable standards of primary health, health population, Aboriginal health and consumer engagement to ensure inclusive, non-discriminatory healthcare services as well as policy and planning that is informed and influenced by evidence-based consumer and community engagement.

It was recommended that the bill be amended to reflect the requirement for the public health system and services to work in a cohesive way to ensure integrated care around a person's needs. The health system should be inclusive of private providers, primary health networks and public health services provided across local government, aged-care, disability and Aboriginal-specific health services. A requirement should be inserted for LHN boards' service agreements and functions and the role and functions of the Health CE to specify that barriers in access arising from the fragmentation of services should be measured and reduced over time.

The probity of boards is an area that I think is immensely important. Clause 12, which removes the requirement for attaching the pecuniary interest to a particular conflict in board minutes, needs to be amended to increase transparency about decisions where a conflict is declared by a member. A further recommendation is to delete clause 11, which broadens the eligibility of board members to include people who are engaged with the LHN. This could include people who are on the boards of private pathology companies or part of a consultancy to the LHN, etc.

I think that last point is particularly important and is something I addressed briefly earlier. That, sadly, was one area where we did try to amend the bill but were not successful. We will be opposing that clause when we get to the debate in the committee stage because we cannot have a situation where, say, you are a KordMentha executive and you have been engaged by the government for a local health network and you also go on the board. What a massive conflict of interest that person would have if they had to keep those services running and keep flowing work to the consultancy that that person was engaged with. What a massive conflict of interest that would be, and it is being opened up by the government through this legislation.

The government's answer is, 'What about a baker who provides bread to the government?' I do not think that anybody would suspect that that would have been covered by the original legislation. This is about specific engagement to the LHN that creates a very specific conflict of interest, which should be prohibited. We should not allow such a blatant conflict of interest to stand where somebody can be a highly paid consultant to an LHN with one hat on and then an independent board member supposedly representing taxpayers and the public interest with another on, with a board that is dealing with multimillion-dollar contracts in potentially billion-dollar budgets. What is being proposed is absolutely obscene.

All those proposals were put by SACOSS, the Mental Health Coalition, the Health Consumers Alliance and all those other groups to all the parties and the vast majority of those suggestions were picked up. I think not all of them are quite able to be picked up because, ultimately, it is a bit hard to change legislation so far down the track in the way that the government has sought to draft it. I think the crossbench and the opposition in the other place did the best they possibly could to amend the legislation, listening to those concerns that have been raised, to try to make sure that this becomes a better bill and ultimately better for the people of South Australia.

I mentioned before that the AMA were also part of that consultation, and they raised a number of concerns as well. They raised these back in April with the minister when he asked for their thoughts on the governance bill back then, and none of them were really taken up. We saw such a dismissive view of the consultation on this bill, and none of these issues were addressed. The AMA raised some the issues in a letter that was written by John Woodall, the acting chief executive of the AMA, on 30 April 2019 to the Hon. Stephen Wade, the Minister for Health and Wellbeing. Under 'Objective and rationale for change', they state:

The AMA(SA) is yet to see the strategic intent in the measures to decentralise governance. South Australians have endured vast overhauls of the health system in recent years, and it might be argued that health has not improved through this cycle of change…We are concerned at the absence of any robust search, evidence or modelling with which to assess or demonstrate the likely success of yet more—albeit limited—reforms as outlined in this Bill.

They also said:

In addition, without clearly defined strategies, objectives and targets, we are concerned that the impacts of change may be felt most keenly in rural and remote regions, where the ramifications of 'siloes' on already under-serviced residents and a stretched health workforce will be most dramatic.

That goes to what I was saying earlier in terms of what the impact will be in regional health services. Every time you talk to anybody in the health system about these governance changes, a few things come out. They say, 'Yes, we have to go through another change,' and there is a bit of change fatigue. Secondly, I think people think boards in the city will probably be okay, but everybody is worried, all the health experts are worried, about what this split-up of Country Health is going to look like and how this is actually going to work.

Here, the AMA spell out clearly that they are particularly worried about what the ramifications will be on rural and remote regions of our state where we are going to see more siloing, more bureaucracy and more pressure on people who work in those health services to meet these new bureaucratic requirements that have been put in place. They also had comments in terms of the Commission on Excellence and Innovation in Health. They said:

Without clear understanding of the role and functions of the Commissioner or the Commission—which we understand is still 'in the design phase'—it is difficult to gauge whether the Commission will fulfil the valuable functions of the Health Performance Council, which you are proposing to abolish.

We would also be concerned if the Commissioner were to report solely to the CEO of SA Health, and not have direct access to the Minister. Similarly, we would query the value of a Commission that was able to report only on the public [health] system and not include an overview of the private system and its interaction with (and resulting impacts on) the public system…

The AMA(SA) is concerned that in abolishing the Health Performance Council the Bill will eliminate the independent and objective oversight of the system the Council has provided since 2008. The AMA(SA) has in the past supported the Council as an independent body that investigates, gathers data and provides recommendations for change. We believe it is vital for our health system that we have in this state an independent body that can investigate and assess the performance of the state's health systems—and that [it] can do so without fear or retribution.

The Council has additionally proven its value in examining the pieces of the health system—public and private, state and national, primary and tertiary—and the issues within it. It has also performed the role of examining the impact of programs that start and stop; to measure their success; and to pinpoint reasons, such as the limited access to data or the absence of measurable targets, that such measurement may not be possible…

In addition, the Council advised that SA Health policy-makers were not paying attention to the needs, ideas or experiences of SA Health staff—the very people on whom a high-quality efficient system relies.

The AMA(SA) is also acutely aware that the Council has identified issues affecting vulnerable South Australians—including the aged and those at the end of their lives, people from culturally and linguistically diverse groups, Aboriginal South Australians, people in rural and remote areas, and young people. We seek reassurance that the 'decentralised' system will be responsive and have sufficient capacity to identify and address these issues, as well as serve the healthcare needs of everyone in South Australia.

The AMA(SA) wishes to ensure that the independent, objective oversight of the system the Council has provided will continue as a mandated element in the new Commission.

Then they talk about system oversight:

Our health system requires evidence, so that we can make the right decisions based on the…knowledge available at any time. The AMA(SA) is concerned that the new governance frameworks are being introduced on 1 July 2019 without clear strategic objectives to guide change or the retention of existing structures. For example, we have only just been asked to comment on a 'design proposal' for the operating structures of regional LHNs. If such structures are only now being designed, we question the readiness of the 'new' to replace the 'old'; what may be missed in the meantime; and who will be accountable for errors that…occur.

That is a particularly stinging comment at the end of April. Only at that point in time was the government starting the process of designing how the local health networks that just started on 1 July were going to operate. I find it very difficult to believe that in two months, May and June, suddenly the government was able to design and perfect and implement a massive structural change for those regional local health networks.

The points that the AMA raised in terms of what would happen if things went wrong, what protections are in place and who will be accountable if they do go wrong, if errors do occur, is a very significant issue. It is worth reminding ourselves that one of the very serious issues, where the previous Health Care Act came about, was about the safety and quality of healthcare services in our state and was when we had boards in regional South Australia going in different directions, getting different equipment, having different processes and different contracting arrangements and having different safety and quality protocols. There were errors that resulted from that.

Who is going to be responsible if we do see errors in this new system? Who is going to be responsible if patients are affected because of that? I fear that the minister is going to try to buck the blame to anyone else. Ultimately, it is a system that he has created, a system that he alone has sought to implement and legislate for the parliament, so ultimately the responsibility will lie with him.

I mentioned before the Charter for Local Health Network Governing Boards, which has been recently put on the website and was established under the Health Care Act 2008, Volume 1, May 2019. A lot of it is replicating what is in the legislation that was passed earlier in terms of the roles of boards and in terms of procedures. But where it gets particularly interesting is in relation to talking about media and communications. On page 12, section 7.5, Media and Communications, states:

Members have a requirement to ensure appropriate and consistent communication occurs. All public comment, including that to any media organisation on behalf of the Board, is to be made by the Chairperson.

The Chairperson may specifically authorise another person to comment on a particular matter. In the absence of the Chairperson, the Deputy Chairperson (if appointed) will address media enquiries on behalf of the Board.

On occasions members may be asked their opinions and when talking to the media members should:

let the Board Chairperson and SA Health Media Unit know if they have been contacted by, or intend to speak to the media, in advance of making comment;

make clear the capacity in which they are speaking i.e. whether they are expressing their own personal views or speaking on behalf of the Board'

remember they are representing the Government and Minister;

remember that decisions of the Board are made collectively, and members share equal responsibility for Board decisions; and

be mindful of, and aligned to, the Board's governance role.

Operational and management media and communications concerning LHNs are managed by the SA Health Media Unit in accordance with the SA Health Media Policy Directive.

The government is saying, 'We are creating these boards. There's going to be independence. Everyone is going to be happy in regional South Australia. Oh, but wait, we're going to issue this directive telling you that all media inquiries are to be dealt with by City Centre, Hindmarsh Square, Adelaide, and you're not allowed to say anything about what is going on in your regional communities. All inquiries have to flow there. Oh, and, by the way, remember you are representing the government, not just the government but the minister as well.'

Far from being independent, SA Health is specifically outlining for these members that they have to represent the minister and that they have to pass things through the SA Health Media Unit. I do not see anywhere in the legislation that says that. So much of this policy document outlines what is in the legislation, but nowhere in the legislation is there any requirement or prohibition, from what I can see, in terms of prohibiting members of the boards from speaking publicly about their local health services. Nowhere does it say, 'You have to go to Hindmarsh Square if you want to say something about what's going on in the health system.' That is something that has just been snuck in very sneakily.

Mr BROWN: Mr Acting Speaker, I draw your attention to the state of the house.

The ACTING SPEAKER (Dr Harvey): There not being a quorum, ring the bells.

A quorum having been formed:

The SPEAKER: A quorum is present. The member for Kaurna.

Mr PICTON: Thank you very much, Mr Speaker, and I am glad that you are here to hear my contribution on this speech. I was just talking about how the government is seeking to limit the rights of board members to have their say and speak publicly about issues in the health system. I think that the internal dilemma in the system that the government is seeking to operate is going to come to the point where there will be issues and we will have to see board members speaking up publicly about their concerns.

Already one board member has written directly to the minister outlining their concerns specifically with this legislation, and that is the board chair (or he was the interim board chair at the time) of the Southern Adelaide Local Health Network, Mr Mark Butcher. He wrote to the minister on 30 April, again just sneaking in before the minister was able to introduce his legislation, and no doubt I think it is pretty clear did not take account of any of these suggestions that were made by people. He raised a number of significant issues. He said:

In preparing the response, I have given consideration to communications I have observed and contributed to at the Department of Health and Wellbeing (DHW), within SALHN and within the group of metropolitan LHN Board Chairs and LHN Chief Executive Officers.

Not only is it his views but it is also reflections upon what he has seen from the other LHNs, who are clearly talking together about some of these issues. He saw a particular issue in the amendment of section 7, the role of the chief executive, and he said that the proposed legislated change of role of the chief executive is noted. He goes on to say:

The new system may benefit if the accountability framework for the [Department for Health and Wellbeing], and its obligations within service agreements, was more clearly defined. Without this additional clarification, the health system's governance reform program is open to interpretation by individuals who may lack essential detail to effect the reform required to underpin an effective holistic system.

He also raised issues, as I was saying, in terms of service agreements and went on to say:

The proposed provisions as described in Part 4A—Service agreements are unidirectional in intent. That is, the sole context is of the Chief Executive negotiating a service agreement with the Local Health Network's (LHN) Chief Executive Officer for services and obligations of the LHN. There is no reference to the need for, or required terms of, service agreements between the LHN's Chief Executive Officer and the CE of the DHW for services and obligations of the DHW to the LHNs.

The service agreements may be enhanced if they specify the volume, scope and standard of services provided by the DHW to the LHN. Amongst other matters this may include such matters as services provided by the DHW's:

Digital Health agency;

Wellbeing SA; and

Commission on Excellence and Innovation.

He also raised significant concerns, as I mentioned earlier, in regard to employed staff. He said:

Whilst there is a case for the LHNs to assume the role as employer for their respective staff, at the meeting between the Interim LHN Chairs, you and the Treasurer, on Friday 5^th April 2019, the Treasurer explained the rationale for the continuation of the CE SA Health as the employing authority. In so doing he suggested that the service agreements would set out significant delegations for matter of employment, effectively transferring significant authority to the LHNs CEOs.

That is very interesting. That does not appear in the legislation, but apparently there has been some agreement by the Treasurer, who we really know is in charge of the government, in terms of what will be part of the service level agreements. He goes on to say:

Without these effective delegations, retention of the CE SA Health as the employing authority poses a risk to a LHN's Governing Board's ability to deliver on their legislated functions…

Specifically, continuing the CE SA Health as the employing authority, in the absence of delegations in the service agreements, may present a tension for the CE SA Health with the new expectations of their role which as proposed, will not have direct accountability and responsibility for management of public health services. Section 14 may benefit from additional clarity in that regard.

This relatively short letter really does set out a number of the contradictions, a number of the issues and a number of what I think will be the brooding problems with this slapdash approach that the government has insisted upon for setting up these LHN boards.

Here we have the CE of the Department for Health, who supposedly is no longer responsible for any health services but is responsible for all the staff who work in those health services. Here we have the LHN boards saying, 'We need some power to manage our staff if we are going to deliver on these service level agreements.' We have the Treasurer saying, 'Don't worry, it's all going to be taken care of in the service level agreements,' but none of that is in the legislation to be dealt with at all, so I would not have any confidence if I were them that any of that would be addressed.

We also have specific concerns about what will go in those service level agreements and, particularly, what will have to come the other way. It is the old: 'What will you do for me?' not, 'What I will do for you.' There is a lot in there about what the LHNs will do for Health, but not a lot about what Health will do for the LHNs. I think Mr Butcher raises a number of concerns in relation to particular areas where the government has chosen to keep control at a central level, such as the Digital Health Agency, such as Wellbeing SA and such as the Commission on Excellence and Innovation.

LHNs will be reliant upon the department for those services, but it is not necessarily clear whether they will be part of the agreement and that there will be targets that the central health department will have to meet in their delivery. It is particularly important when you are looking at Wellbeing SA, which, as I said earlier, is an organisation where the government has sought to combine a whole range of functions that were already done centrally within the department.

The rumour is that the way the minister is trying to get around the fact that the Treasurer will not give him any money at all to run any out of hospital programs is that maybe he is going to pull out from those local hospital networks those services that are done out of hospital and stick them in Wellbeing SA. Not only will they then be stuck centrally in Wellbeing SA but the government may well go about a process of privatisation of those services. This is being talked about. That is a very significant change. We know from discussions this week this government's love for privatisation that they have shown already, so it may well happen that we will see a centralisation and then a privatisation of those services.

At the same time that the government is saying they are devolving things, they are just devolving the hospitals. All those other services that those hospitals rely on to reduce their pressure are going to sit centrally and those boards will again be in a tough position because they will not have the ability to control them. They will not have the ability to have any oversight and they will not have the ability to know whether those services are actually being delivered or not.

They also will not have the ability—and I would have thought this was pretty central in the role of running an LHN board—to decide, if they have X amount of money, how much they are going to spend on the acute system, how much they are going to spend on the primary system, how much they are going to spend on digital health and how much they are going to spend on a range of other areas of the health system, because the government is hoovering up some of that. They are holding it centrally and just being told, 'Well, you're just running hospitals.' Well, that is a very narrow lens through which to view the health system.

These were specifically set up in the Health Care Act to be local health networks, not local hospital networks, because it is so important that they have a broader remit than just running the hospital. I think that they should be doing more, not less, in that and that would certainly help the running of our health system. That is a very significant letter to get from a significant person that the government themselves have appointed to be in charge.

This is a bill that has improved significantly from where we started. Originally, we were facing a bill that I think was going to cause a huge amount of damage by setting back by quite a long way our oversight of the system with the Health Performance Council being abolished. Sadly, the government wanted to pursue that. Luckily, we have taken that out in the other house. I do note that I think that there was one amendment that the upper house missed that still references getting rid of the Health Performance Council, so we will seek to oppose that in the committee stage here.

We will also be opposing one other section that slipped through the Legislative Council in terms of the oversight of the system by members of the board who could be engaged themselves as consultants for, say, a KordaMentha-type company while at the same time they are on the board of the company. That is a massive conflict and I think we need to stamp that out.

But there are elements of the bill that are good now. There is an element of the bill to enshrine the Health Performance Council. I note that the government is saying that this is not a perfect way of drafting it. Well, of course not. We did what we could to try to save this organisation. It would have been good if you had done it and we did not have to do it, but we are trying to save this organisation from you gutting it—gutting all its staff, gutting its independence and sacking the existing commissioner, who everybody regards as having done an exceedingly fantastic job since he has been appointed.

We were also trying to make sure that the bill continues its clause in relation to consumers and a chief executive having a role to make sure that there is at least a body centrally that is representing consumers—

Mr ODENWALDER: Point of order: sir, it is my solemn duty to draw your attention to the state of the house.

A quorum having been formed:

Mr PICTON: As I was saying, we think it is important that we do not have people who are engaged by the local health network and on the board of the local health network because that is a direct conflict of interest, particularly when such vast sums of taxpayers' dollars are at stake. I have to correct one thing I said earlier when, off the top of my head, I said that some of the people who work for KordaMentha are being paid in the order of some $800 a day. Deputy Speaker, I regret to inform you that I vastly underestimated the figures. On double-checking my listing from off the top of my head, I referred to an article from the Adelaide Advertiser dated Thursday 7 February 2019.

Mr DULUK: Point of order, Mr Speaker: it saddens me that the member for Kaurna referred to you as Deputy Speaker when, of course, you are the Speaker of the house.

The SPEAKER: That is true. I am sure he will correct himself in future addresses.

Mr PICTON: It was a mere mistake. What gladdens me is that the member for Waite is paying such attention.

The SPEAKER: He never misses a beat.

Mr PICTON: He might be very interested to know—

Members interjecting:

The SPEAKER: Order!

Mr PICTON: —my correction of the payments that KordaMentha staff are receiving. On 7 February 2019, an article by Mr Brad Crouch in the Adelaide Advertiser, called 'Health repairs a costly business', outlined the payments being received by KordaMentha staff. What do you think the daily rate is? I said $800 before but, no, that is way off. Is it $1,000? No. It is not $1,000 a day, $2,000 a day, $3,000 a day or $4,000 a day. It is $5,166 per day that these staff receive as part of this administration. There are three staff on that rate. One staff member, a subcontractor, was getting $6,492 a day.

Mr Odenwalder: That's a lot of nurses.

Mr PICTON: 'That's a lot of nurses,' says the member for Elizabeth. That is right. How long would a nurse have to work to get $6,492, let alone a cleaner? Quite a lot longer than one day, I suspect. At the same time, this is a government that is putting up car parking rates by $725 a year for some of our lowest paid workers in the Public Service: cleaners, orderlies, care assistants and enrolled nurses. Those people are being stiffed.

These people, who are all interstate, who are all external contractors who live in Sydney, Melbourne and other places—they do not live here—are getting paid thousands and thousands of dollars every single day. That is the sort of governance that we are seeing under this government. That is the sort of approach that they have to the health system. It is delivering awful results so far under their tenure. We see the results getting worse every single day.

We have a confused, mismanaged approach to this governance reform that is being criticised across the board, from stakeholders and clinicians to even the board chairs themselves. It is set up to potentially send our health system backwards. I hope that the health minister actually listens to some of these people who have raised these significant concerns because, ultimately, if these systems fail, then people will suffer as a result. I conclude my remarks in regard to this bill.

Members interjecting:

Mr PICTON: I am happy to keep going. I think it is very important that the elements of the bill that were changed by the Legislative Council remain, and that those clauses that I have outlined that need to be opposed are opposed by this house so that there is a chance of this system slightly working and not being further to the detriment of health in this state.

Debate adjourned on motion of Hon. J.A.W. Gardner.