HEALTH CARE BILL

Second Reading

Adjourned debate on second reading.

(Continued from 25 October 2007. Page 1185.)

The Hon. A. BRESSINGTON (17:20): This is one of the most important bills I have been involved with since my election to this place, and certainly the most significant in the health portfolio. It is also one in which I am yet to decide my position. The bill was introduced by the Minister for Health into the House of Assembly on 27 September 2007 and passed on 24 October. It seeks to introduce reforms to the governance and administration of hospitals and health services. Significantly, it provides for the abolition of hospital unit boards and the introduction of centralised decision making, and it has been this in particular that has caused debate on the bill to be quite emotive at times.

I note that in the initial stages of consultation, after a draft bill was issued last August, community leaders, hospital board members and others treated this legislation with a high level of suspicion and even paranoia. There certainly exists a strong sentiment of distrust in our regions over the centralisation policies of this government, and not just in health.

Centralisation is seen by many as a blow to already struggling regional South Australia, which is still reeling from the worst drought in living memory, rising interest rates and spiralling petrol prices. The signs are everywhere that regional South Australia is on the decline, and has been for quite some time. For example, late last year the government announced that 44 full-time equivalent Public Service employees from the South-East would be axed and relocated to Adelaide.

Media coverage in the South-East was highly critical of the government, with radio hosts and newspapers alike suggesting that, rather than focusing solely on the economic benefits of such a plan, the government must give greater—or at least equal—consideration to the social cost. This same argument has been made by the opposition in relation to the bill.

I note that this month (February) the Provincial Cities Association declared that it wanted a study into the effects of public sector jobs centralisation. Head of the PCA Port Augusta, Mayor Joy Baluch, said that the government's shared services plan, which would move about 250 regional public sector jobs to Adelaide, lacked detail and that she was still opposed to it. Any reduction of staff in the region has repercussions in other areas, and many support the view of the association that the government should be decentralising.

There are also issues other than purely economic ones to consider. Many of the people who will be affected by this legislation have established social networks and are part of the community, and they and their families will feel a significant impact. It is important for government and bureaucracies to recognise these concerns, as there are quite a few people in this state who feel it is indicative of the government's negative attitude towards the regions.

The word 'centralisation' incites fear in our regions, so when it is associated with this bill the alarm bells start ringing for many. In this bill we are being asked to consider the centralised employment of about 25,000 employees of the Department of Health, with its regional offices and services it provides in the community. Perhaps there is merit in some of these concerns, as regional areas tend to host safe Liberal seats and would, therefore, perhaps not be seen as a government priority.

Last year, when the draft bill was up for consultation, the opposition, led by shadow minister Vicki Chapman, was very vocal in its criticism. The essence of its attack was that the government was up to no good and that it had hidden motives. At the forefront was the proposal that not only would hospital boards be removed but also the proposed health advisory councils would simply give communities a voice with no influence.

In a September media release Ms Chapman noted that, in its health reform documents of June 2003, the government stated that, 'there will be no forced removal of local boards in country South Australia', yet within 18 months regional country boards were abolished, and local hospital boards were next in line. This was because health boards were a nuisance, we were told, protected from the minister interfering with their assets, staff selection or delivery of service but able to criticise and raise some uncomfortable issues with the government. In turn, the government—of course—accused the opposition of scaremongering.

Nostalgia plays an important and undeniable part in opposition to this bill, as these boards have been an integral part of regional communities for many years. Of course, the government is telling us that this bill is about looking to the future and making changes to an outdated system and that the present legislation was developed more than 30 years ago and is in urgent need of reform. In the words of the minister, significant challenges to the health system exist which 'make it increasingly difficult for the public health system to meet the demands in a cost-effective and equitable way unless reforms to the health system are instituted.' However, the opposition sees it as a cynical grab for power.

In consulting for this bill my office contacted numerous board members throughout the state. At first there was considerable opposition to the hospital boards being removed. Their removal, especially in the absence of a regional structure, was seen as a slap in the face to the boards and their contributions to this state over the past 160 years. There can be no doubting the role played by boards in rationalising and regionalising health services, so many members were particularly affronted by this. In addition, the subsequently established health advisory councils were seen as likely to have no real influence. This is in direct contrast to the historical role of boards being strong advocates for local communities.

The government said that, as health advisory councils will consist of appointed and elected positions, the majority of whom will be local committee members elected at an annual general meeting, the needs of the local community will be met. However, my staff spoke to some board members who were very distressed about this matter and who vehemently opposed this legislation. They were concerned that they would be able to do little more than raise issues at meetings with no guarantee of any follow-up. As already mentioned, this is in stark contrast to their present influence, where they have significant input on direction and policy advice and make strategic planning decisions.

As pointed out by many of the opposition members, there is a real difference in the way health services are delivered in country areas and metropolitan Adelaide. However, after speaking to many of these people again recently it does appear to me that sentiment has changed and opposition to the bill has reduced. A board member of the Port Lincoln Health Service, who was initially outraged by and vehemently opposed to this reform, has since told my office that, while she still has some concern that the role of the council will now be merely to rubberstamp directives, she is much more relaxed about it.

That said, this is certainly not exclusive. The Balaklava and Riverton District Health Service is one that continues to openly state its opposition to the abolition of local boards, and individual board members continue to say the same thing to my office. In addition, the opposition says that many of the hospital and health service boards have been worn down; they have eased their resistance and have simply given up, they are sick of the fight. I have to ask the question, though: if this was really so important to them would they just roll over and die? That is not the Australian way, and certainly not what I would expect from the proud, salt-of-the-earth Aussies living out in our regions.

I now return to what was, according to the minister, the driving force behind this legislation: the Generational Health Review report. In this report the author, Mr John Menadue, details some of the pressures on the health system. Now, having monitored the debate in the other place, it is quite apparent to me that the government and the opposition are each interpreting the observations of Mr Menadue in this report in such a way as to fit their already formulated agendas while seeking to simultaneously discredit the other side. Such is politics.

According to the minister, the report 'clearly identified fragmentation and duplication of planning, funding and governance arrangements as major inhibitors to development of a coordinated health system, and a systematic approach to improvements in health outcomes to South Australia.'

Although South Australia has a pretty good health system overall, I can see where the minister is coming from when he says the governance arrangements in SA are not keeping up with the requirements of a modern integrated system of health services. It may well be possible that these legislative changes will facilitate improved governance arrangements in our hospital system. I have been impressed by some of what the minister has had to say but, as yet, I have not seen enough to convince me that this will actually be the case.

The minister has stated that if reforms are not made to our health system it will eat up our state budget in future years. By cutting through the bureaucracy, the minister says this will enable the public health system to have a much better capacity to act as a coordinated, strategic and integrated system. Under this bill the CEO of the Department of Health will have direct responsibility and accountability for managing the public health system and not just funding it. As mentioned previously, although the metropolitan health regions will continue to exist, there will be no boards and the CEOs of the metropolitan regions will report directly to the CE of the health department.

Similarly, in the country, we currently have 43 hospitals which are separately incorporated. These hospitals will be combined to form Country SA, which will be incorporated as a hospital in its own right. However, we have the shadow minister saying that the government has simply cherry picked points made in the report. The shadow minister noted that the government's own report says that local community participation in health care agencies and issues needs to be maintained and strengthened. It is important to recognise the continuing interest of local communities in assets that they have funded and to support and encourage ongoing fundraising and contribution in kind.

According to the opposition, this bill fails at every level to actually provide what Mr Menadue also recommends, that is, regional structure for a voice and a capacity to remain directly involved. The shadow minister stated that Mr Menadue was quite clear in his recommendation that it was necessary also to make sure that services were provided at local level and that it was important to include the people of South Australia who have an interest or an alliance with the area—referring to those involved in the nursing and caring services, patients, clinicians, hospital administrators, departmental advisers and so on.

I note that the member for Schubert was one of many opposition members who was very vocal in the other place in criticising the winding down of country health. The member passionately believes that, as these people are much more familiar with the local issues than some bureaucrats in his or her office in Adelaide, the influence of board members having real authority is absolutely vital. I certainly recognise the concern that centralising the governance will cause communities to be disconnected from their hospitals, and that this will probably see the delivery of services worsen in regional South Australia. One member even said that the bill would be the death knell for services in the country if it was passed, making it extremely difficult to attract and retain GPs in rural communities.

Whether or not the Liberal's concerns are overstated, there are other issues to consider. For example, Mount Gambier does not presently have a palliative care ward, and this has caused significant emotional pain for the residents. Perhaps the establishment of a super hospital there will provide very positive and long overdue development. Last month, in January 2008, my office became aware of the sad story of a terminally ill Mount Gambier man who was sent to Penola Memorial Hospital to die. Mr McQuade, a Vietnam veteran, was transferred from the Mount Gambier facility as a doctor did not consider his condition to be acute. He died 10 days later. His widow, Carmel McQuade, publicly criticised the Mount Gambier Hospital, telling local media that the transfer of her husband was extremely traumatic as Mr McQuade had wanted to remain in Mount Gambier to be close to his family.

Mr McQuade's brother, who lives in the Mount Gambier district, and Mr McQuade's son, who had travelled from Brisbane to be by his father's side, visited him daily before his transfer to Penola Memorial Hospital, 50 kilometres away. Mrs McQuade said that this added stress to the family at an already difficult time.

Hospital management defended the treatment of Mr McQuade, with the Lower South East Health Services director, David Walshaw, saying there was no need for patients to remain in an acute hospital once their condition had stabilised and that Penola's facility was under-utilised and could accommodate increased activity. Mrs McQuade said that her husband weighed less than 30 kilograms when he was admitted on 19 November, and that she knew his death was imminent due to his oesophagus cancer being compounded by a number of other serious health concerns.

Due to health problems, Mrs McQuade was unable to care for her husband at home and felt that she was not properly consulted about the transfer. She said that she was so distressed about how the family was treated that she was unable to sleep. There is something seriously wrong with our health care system when terminally ill patients are further stressed by being forced to die away from their home and loved ones. Indeed, this issue has dominated local media in the past month with residents and media commentators alike highlighting the urgent need for palliative care facilities at Mount Gambier Hospital.

'This is something we need as soon as possible. I don't agree that people should be sent away. They should be kept in the same town,' a local said. Mount Gambier certainly is not a small town, either. With more than 24,000 residents it is the second most populous city in South Australia. It has a 90-plus bed hospital and has been earmarked to become a major regional referral centre. Residents quite rightly feel they deserve such facilities. 'We definitely need these facilities,' said one local. 'For someone who is terminally ill, it is very necessary. Anything that can make it easier for them and their families is very important to us. We definitely need them here,' said another. 'My brother-in-law has cancer and he needs the service,' said another.

I note that minister Hill demanded answers from the Mount Gambier Hospital over the incident and explained that, under this bill, the hospital was one of four statewide being established as a large general country hospital. The issue of palliative care is becoming more important every day and, with the region's ageing population, this type of service will be even more necessary in the coming years. Providing more elective surgery, rehabilitation and palliative care services will greatly benefit Mount Gambier but, as the state's largest provincial city, it does beg the question: why are we not already there? It seems ridiculous that palliative care is available in Penola but not Mount Gambier, which is 10 times bigger.

This is not something that has only recently become a concern. Three years ago, a telephone survey of residents revealed that the most important state government service for people within the area was health and medical services.

However, whilst the establishment of the 'super hospitals' will be good for people living close to Mount Gambier, Port Lincoln, Whyalla and Berri, what about those who do not live near these cities? What about the people who travel to these areas from Adelaide? They need these health services, too. That might have to be an accepted consequence of a person's decision to reside in or to visit a small town, where it is understood that travel may be required to access certain services. However, there is no doubt that a considerable burden is placed on those living in a town like Cleve on Eyre Peninsula, where there is no GP or obstetric and postnatal services, and women must travel to Whyalla or Port Lincoln to give birth.

The Liberals have expressed fear that the situation will get worse and that this legislation spells the end for country hospitals. Again, they may be overstating the situation in order to be seen as sticking up for their electorates. However, it is certainly my view that a satisfactory level of health care must be provided to regional South Australia as well as to Adelaide.

A Streaky Bay resident has been very vocal in her concern that, with the new hub concept, only Port Lincoln, Whyalla and, some time in the future, Ceduna are to be upgraded to provide services for Eyre Peninsula. What will happen to the others? Will they waste away to a slow and undignified death or will their life support be cut off and services immediately closed?

Even though it is reasonable that the major focus be on the capital, as this is where the majority of South Australians live, the government needs to further allay fears of a downturn in services in our regions, especially when the government is constantly reminding us about the mining boom on the horizon and how that will be the future of our state.

When it all boils down, the issue for honourable members to consider is: will this bill provide better health care for South Australians? South Australia has a very good public health system, staffed by committed health professionals and administrative staff. However, South Australia is repeatedly identified as the poorest performing mainland state when it comes to elective surgery and other vital indicators of performance.

For example, out in the community, people are waiting years for surgery to relieve chronic pain and immobility that sentences them to confinement. In fact, we have the longest elective surgery waiting list ever recorded in this state, the worst emergency response times in the nation, and the lowest mental health and elective surgery funding per capita in Australia. So, there is certainly room for improvement.

The bottom line is that all of our health services must be up to a certain standard; not only that: they must be progressive. We need safe and effective health services for the future. Making things more efficient—as the government says these reforms will do—would certainly be a good thing. We need to provide a more sustainable public health system, with better and more equitable outcomes for our population.

So, will the new governance arrangements ensure a greater capacity for the health system in this state to act as a coordinated, strategic and integrated system to help meet the challenges of health pressures into the future or, as one opposition member said, is this socialism at its worst? Although I am leaning to the former, I am still yet to be convinced—and the question of why the government has done a back-flip on its 2003 promise not to get rid of hospital and health service boards does trouble me somewhat.

The government's reluctance to have independent board members with significant influence on policy draws parallels with some of my key concerns with the SSABSA Bill, which I did not support. As I have said, I am yet to decide my position on this bill either way, and I look forward to hearing the contributions of other members to this debate.

The Hon. J.M.A. LENSINK (17:41): On 23 October 2007, in the House of Assembly, the member for Bragg (Vickie Chapman) outlined the very comprehensive and extensive reasons why the Liberal Party does not support this bill; indeed, the honourable member who preceded me in this debate has referred to some of that debate.

This bill is essentially about governance. It has a range of measures, including the establishment of health performance councils, health advisory councils and the like, and it basically transfers the influence within the health system to be concentrated around the minister and the CEO of the Health Department, and that is something to which the Liberal Party is fundamentally opposed. The preceding speaker outlined a number of individual cases where people have been disadvantaged by our health system, and this bill will make that situation worse.

My understanding of the Menadue recommendations is that he proposed that we have a population-based health system. When it comes to the country health regions, it is completely all over the place. In terms of this bill, it has been described to me as the government drawing a circle around Adelaide. Effectively, two of the 'super hospitals' will be established on Eyre Peninsula for a population of 28,000, yet the combined areas of Mid North, Barossa and Yorke Peninsula have a population of 110,000.

The government has claimed that no-one will have to drive more than two hours to get to a hospital, but a number of people in regional and rural South Australia will have more than a two-hour drive to get to any hospital. Effectively, this will downgrade the other country hospitals, and they will be left as basically GP proceduralist rooms to enable the government to completely centralise power within head office.

Country South Australia has been described as a minority, but it actually comprises half a million people of our 1.4 million, which is more than one-third of the population of South Australia. They are responsible for a large part of our agriculture and mining production and so forth, yet they are being treated very shabbily in this change to our health system.

Hospitals are very important in many communities. They bring additional people into the workforce and they are also very important places for training. Indeed, in my own profession I spent some time at the Murray Bridge Hospital as a student. They provide very important places for training and I believe that new graduates, in particular, will be scared of going to work in regional places because they will not be able to obtain the same amount of training and support as they have in the past, which is short-sighted when we have a workforce shortage in this state and we are lessening the opportunities for young people to undertake training within our health system.

I note that the AMA had some cautious criticism of this bill, in that in his CEOs report Duncan Wood stated that the bill establishes a new health performance council which is advisory in nature and is charged with the responsibility of independently reporting on health system performance. Whilst hope springs eternal, he says, about the potential effectiveness of newly created health advisory bodies, the AMA(SA) did request the bill be altered to allow for consultation with the medical profession and other groups in the selection of appointees, as well as ensuring that the body is appropriately resourced to fulfil its function.

I think there is some concern within the medical profession, in particular, that there are some anti-doctor people within the health department. As a physio student, I do recall receiving some lectures from certain people who did a unit who did try to downgrade the importance of doctors. I note too that the GPs have not signed the memorandum of understanding that exists with the Ambulance Service and mental health and so forth, and that they believe that their role in terms of mental health is being downgraded, which is just another factor within the government's attitude towards doctors.

Most recently, in The Border Watch, the local people have gone public and expressed their disappointment in relation to this bill. The Grant District Council is angry with the state government because it will no longer have any governance over the Mount Gambier Hospital board. I note that in this article, dated 7 February, it states:

The Local Government Authority yesterday put forward its case to member for Mount Gambier Rory McEwen in a telephone linkup, including South-East Local Government Association representatives.

Clearly, the member for Mount Gambier has fallen into lockstep with the Labor government in that he has not made any effort at the cabinet table to represent his local constituents and the board members of the Mount Gambier Hospital. Indeed, councillor Alan Hill has resigned from the hospital board in protest. So, I think that goes to the depth of concern that the locals have with this issue.

Probably one of the most significant areas in which the local communities who will be relegated from their current roles into merely being members of health advisory councils is that they do not have any financial control. I greatly appreciate the briefing that was provided to me by the department through the minister's office, but my suspicion is that they have just adopted a one-size-fits all approach. There may well be some communities who would be happy not to have control of issues such as hiring and firing and any other business decisions that need to be made within the hospital, but I am sure that that is not the case for all hospitals.

I think that is a reflection of the approach that this government has; that it likes to internalise control within itself rather than trusting local communities to manage those issues for themselves. It is beyond me and beyond my reasoning to understand how taking control away from local communities will result in better outcomes for those people. They will need to put their concerns in to the centralised organisation, and the organisation can then choose whether or not to take that advice on board. There may be specific local issues that come up, such as whether one particular region is experiencing a downturn. There may be increased road accidents as a result of that, increased violence or any sort of issues that may arise, but really that impact on the health of those local communities may well be ignored by the powers that be.

There are some areas in which I think this bill will improve systems, and that is in relation to adverse incidents and root cause analysis. I understand that there is some confidentiality required in terms of incidents because that encourages people who are involved with that incident to actually be much more frank about what may be a systems problem, or a particular incident or, indeed, a particular individual, and that is to be applauded.

I also note that new clause 75 relates, effectively, to additional whistleblower protection, which I think is also a very important issue within our health system, namely, that people cannot be victimised if they provide information that is to the benefit of the health system. Having worked in a hospital, I am very aware of the hierarchy that exists within such an institution and that people may be afraid to speak out for fear of retribution. I note that the issue of the licensing of private hospitals will be dealt with at some later date and that a range of information is consistent with provisions within the new mental health bill.

I do not wish to speak at length on this bill, because I think that many of the issues that are of concern to people have already been raised in the debate. I reiterate that the Liberal Party is very concerned about the impact this will have on public health. I have specific questions for the minister: what will be the difference between the clinical senate and the new health performance council and which parts of the health system will those bodies have responsibility for within our system?

Debate adjourned on motion of Hon. J.M. Gazzola.