HEALTH CARE BILL

Second Reading

Adjourned debate on second reading (resumed on motion).

(Continued from page 1728.)

The Hon. M. PARNELL (17:09): In speaking to the second reading of the Health Care Bill, the first observation I make is that the title of the bill is misleading. It is not really a health care bill: it is really an administration of ill health bill. I think that it would be obvious to all honourable members that, when we look at definitions of true health and work out the indicators of true health, we need to go much beyond ill health, hospitals and medical practitioners.

True health is determined by a range of factors, including education and poverty, and also issues such as infrastructure in our cities and towns—for example, public transport, water and clean air—and issues of asthma related to air quality and obesity connected with sedentary lifestyles and the lack of walking or cycling opportunities. All these things make up the mosaic of health issues.

In relation to the bill, I also note that there is probably a great deal of reform fatigue in this area. The debate over centralisation or decentralisation has continued for many years, and a great many people who would otherwise engage robustly in a health debate have probably run out of puff.

One group whose contribution to this debate I acknowledge is Health Reform South Australia. One of the documents it sent to us (it went to all members of the Legislative Council) in relation to the bill stated:

Health Reform South Australia is broadly supportive of the reforms proposed by the bill, but we would like to raise a number of issues for consideration by members. In particular, we have concerns in the areas of community participation, the excessive centralisation of decision making and accountability mechanisms in governance. These are key areas of the reform process which have been largely overlooked in the past.

It raises a number of specific concerns about the bill, for example (and other members have referred to this), the independence of the Health Performance Council and the levels of transparency and accountability, and it has proposed alternative models for a body with such functions. It also makes the obvious point, but a point that I think is overlooked in the bill, that reforms to the health system have to result in improved health outcomes for South Australia.

Dealing with hospital administration is not the primary tool for delivering those improved health outcomes. The submission of Health Reform South Australia states:

For these health outcomes to occur, the focus must remain on comprehensive primary health care, a population health approach, accessible and appropriate preventative health and health promotion programs, and the health literacy of the community. Although a focus on these may not require legislative change, they must not be subsumed or neglected in the processes of reforming the tertiary sector.

I think that a point worth making is that, in the Health Care Bill, we are dealing with only a small part of the overall health picture.

One of the problems with the health debate in recent times, and in this bill in particular, is that the debate is all about hospitals. I think that we need to take hospitals away from the centre of the debate. I will to refer to a few words of John Menadue who, as members appreciate, was the Chair of the Generational Health Review. In an article published in April 2005, he stated:

We have the wrong model of health care with the hospital at the centre. The best model is where there are strong core services in the community—primary care—that is linked to hospitals but not driven by hospitals.

There is ample evidence that we have got the cart before the horse in health care with our emphasis on hospitals. We have more hospital beds per capita than comparable countries—about 50 per cent above the Canadian rate and 30 per cent above the US rate. In some states almost 70 per cent of state health dollars are spent in hospitals. The health debate is invariably about hospitals.

John Menadue goes on to state where the emphasis should lie. He states:

By a primary health care system, I mean a system which focuses on population needs, rather than institutional interests, that addresses the social determinants of health, particularly poverty and disadvantage, focuses on health promotion, illness prevention and early intervention, ensures equitable access to health services and has community involvement and participation. Such an approach recognises that there are limited resources and that we need to maximise the wellbeing of the population within those resources.

So, it is somewhat disappointing that we focus so much on hospitals. We have only to look at the debate around what has become known as the 'Marge', the proposed Marjorie Jackson-Nelson hospital. The debate has revolved around, first, whether we need a new hospital and, if we do, where it should be located. It is an ongoing argument. I am not convinced that the government has got it right, and I know that the opposition has some concerns about the proposed location.

I even had one piece of correspondence from Dr Ruben Seben of the Queen Elizabeth Hospital, who suggested that, if you were serious about putting a hospital at the centre of where it is most needed, and if you were looking to get something that is accessible by a large proportion of the population and equidistant between the two large hospitals of the Lyell McEwin and Flinders, you would put it on the Cheltenham racecourse site. I am not advocating that, but it just goes to show that the debate that is out there needs to run a few more miles before we decide on whether to rebuild a hospital in the city.

The minister has made strong commitments in relation to the potential for the community voice to be heard in this health debate, and I think it is important that we hold the government to account on that. So, at this second reading stage, I urge the government to continue its consultation and perhaps to go a little slower; through consensus, that may prevent having to deal with the great many amendments to this legislation which, as we have seen in the past, can not only be confusing but also have unintended consequences. At this stage, I am happy to support the second reading of the bill.

The Hon. G.E. GAGO (Minister for Environment and Conservation, Minister for Mental Health and Substance Abuse, Minister Assisting the Minister for Health) (17:17): I rise to make a few summarising comments in relation to the second reading debate on the Health Care Bill. I take this opportunity to thank all honourable members for their invaluable contribution to the debate thus far. Before going on to make specific comment, I table a number of documents: the explanatory note to the draft constitution for Country Health SA Board Inc., an incorporated health advisory council to be established under the bill; an explanatory note to the draft model constitution for incorporated health advisory councils; an explanatory note to the draft model rules for unincorporated health advisory councils; and, the AGM attendances and other general information during 2005-06.

The bill is an important piece of legislation designed to provide South Australia with a more integrated and coordinated public health system where, appropriately, responsibility and accountability rests with the Minister for Health. Its importance and significance as a comprehensive and sound bill has been acknowledged by members in another place, with the bill being passed on 24 October 2007, without amendments being tabled by the opposition.

During the course of the debate on this bill the term 'centralisation' has been used a number of times by members opposite to describe the intent of the bill. I make clear that the bill is not intended to centralise control, as has been claimed, but is about creating better governance arrangements to ensure that health services can be managed more effectively and efficiently.

Under the bill the current metropolitan incorporated hospitals (the Central Northern Adelaide Health Service, the Southern Adelaide Health Service and the Children, Youth and Women's Health Service) will be retained. In addition, Country Health SA will be established as an incorporated hospital when the proposed act comes into force. Each incorporated hospital will have a chief executive officer who will be responsible for its management and who will report to the chief executive of the Department of Health. Consistent with commitments the minister has made to veterans, the Repatriation General Hospital will remain as a separate incorporated hospital, governed by a board of directors, until such time as it wishes to become part of the broader Southern Adelaide Health Service.

These governance arrangements do not create a centralised control or employment of staff. It was the Statutes Amendment (Public Sector Employment) Act passed by the parliament in 2006 that made the chief executive of a department the employing authority. Therefore, the chief executive of the Department of Health is already the employer of all staff in the public health system. The bill does not change the employment relationship between staff and the chief executive but is consistent with the Statutes Amendment (Public Sector Employment) Act 2006.

The chief executive will be responsible for the administration of all incorporated hospitals and subject to the direction of the minister. However, the day-to-day running of the hospitals and health units will rest with the chief executive officers of the incorporated hospitals. Therefore, appropriate levels of decision making and management will remain.

What will change in line with clear and strong community expectation is that the chief executive and the minister will be more directly accountable and responsible for all parts of the health system. The chief executive should have the functions and powers consistent with this responsibility and accountability. At present there are fragmented accountabilities and responsibilities between the incorporated hospitals, health centres, the boards and the chief executive, making consistency in the planning and delivery of services for the benefit of all South Australians difficult to achieve.

Under the bill, this fragmentation is removed ensuring a greater capacity for the health system to act as a coordinated, strategic and integrated system that can meet the challenges facing the health system into the future. A second theme emerging from the debate is a claim that the needs of people in the country region are being ignored, or not seen as significant. With the establishment of the Health Advisory Council (HAC), the power and influence the local community currently has through the local hospitals boards will not be lost.

The Minister for Health has consulted very extensively in the country region and the bill before the house represents the outcomes of those extensive consultations. The bill gives specific recognition to the country regions in its principles. It says:

The planning and provision of health services should take into account the situation and needs of people who live or work in the country or regional areas of the state, including through the support of health professionals who provide services in those areas.

Therefore, the bill enshrines in legislation the importance of the country region. It is not dismissed as a minority group. The bill ensures that, when the local hospital boards become incorporated (HACs), the assets held by the local boards will continue to be held by the local and incorporated HAC which replaces it.

Similarly, the incorporated HAC will continue to manage gifts and trusts currently held by the boards, or raised in the future. These local country HACs will operate independently (as they do now); continue to advocate for their local community, and provide advice on the health needs and the services that are required to meet these needs. Their functions are well described in the second reading tabled in the house and in the bill, so I will not repeat them now.

In effect, HACs will, like the boards they replace, continue to have central control in advising on local health needs in the strategic planning of services and in the engagement of volunteers and carers. Again, like the boards, they will continue of their own volition to be able to provide advice to the local health services, and directly to the minister, as well as to Country Health SA and the department.

There is no loss of influence, nor is their advice tokenistic, but it is essential for the planning and delivery of health services in the country region. Responsibility for functions related to safety and quality, financial management (apart from locally owned assets) and contracts will rest with Country Health SA to allow a coordinated and system-wide approach to be undertaken in relation to these.

This change is consistent with the overall purposes of the bill. Membership of these HACs will be predominantly decided on by the local communities, with the majority of members being elected at annual general meetings. HAC membership will also include a representative of the local member of parliament and local government, a medical practitioner and up to three members appointed by the minister. The intention is to ensure there is a majority of local members. These arrangements will ensure local community involvement with health services is maintained.

During the public consultation on the bill, it became clear that the main concern of the current country hospital boards and country communities was to ensure that the HACs will continue to hold assets owned by the local health services. The bill reflects these wishes.

In addition to incorporated HACs, the bill allows the minister to establish advisory HACs related to specific population groups, health issues or services to provide him with advice as required. These unincorporated HACs will be governed by a set of rules. An incorporated HAC will be governed by a constitution and an unincorporated HAC by a set of rules. I have tabled a copy of those along with the explanatory notes for the benefit of the house. The model constitution and rules can be varied so that they are more reflective of local circumstances and needs.

An independent Health Performance Council (HPC) is established by the bill. This is an important initiative to ensure that the minister receives independent advice on the health system's performance in relation to the health status of South Australians. The council will be required to deliver annual and four-yearly reports to the parliament, and the Minister for Health will be required to table a response to the four-yearly reports. The council's membership will include a mix of persons who together have the necessary skills, knowledge and experience for the council to undertake its functions and can represent South Australia's diverse communities.

The calibre and expertise of the HPC members will ensure that the HPC can independently analyse and report on the information and data provided to it. The independence of the council will be assured, as members will be included from areas outside of the department; and the minister will consult with a range of non-government organisations to be prescribed by regulation to advise on suitable members. The Australian Medical Association will be included in regulations as a body with which the minister must consult in relation to the membership of the HPC.

The shadow spokesperson for health asked: what will be the difference between the Clinical Senate and the new HPC, and which parts of the health system will those bodies have responsibility for within our system? In summary, the HPC will be responsible for providing a wide range of advice focused on the overall operation of the health system and service delivery, health outcomes and population health needs and future health priorities. The purpose of the Clinical Senate is to provide a forum where clinical leaders within the South Australian health system share their collective knowledge, provide advice, leadership and guidance on clinical issues, and participate in the decision-making process in relation to clinical health planning.

Its members come from a range of medical, nursing and allied health areas and will be appointed by the minister. It will act as a principal, independent source for clinical advice to the chief executive of the Department of Health. It has as its main focus clinical services and clinical services reform, safety and quality, and the integration and coordination of these services. The Clinical Senate then has a more defined focus than the HPC and, although the exact relationship between the Clinical Senate and the HPC is yet to be defined, since the latter is still to be established, it is expected that the HPC could well ask the Clinical Senate to review or provide advice on specific matters before the HPC where they relate to clinical services.

A number of statements have been made about access to and the quality of health services in the country region. This bill is not about the health services that will be delivered; it is about the broad governance arrangements for the public health system. The deep bond that country communities have with their health service will continue. The community will continue to own its assets. The questions about the services themselves are being addressed in South Australia's Health Care Plan and the draft Country Health SA Services Plan to be released for public consultation later this year. Generally, however, country people will have to travel far less to access a higher level of service, that is, they will not always need to travel to Adelaide. They can, of course, do so if they so choose. The overall intention is to increase the availability of health services in country locations.

The country general hospitals being established will ensure that there is a greater range and complexity of services available in the regional areas of this state. This will provide broader clinical experience for those training as a health professional and support building a relationship between those training with the country regions. Through this, the opportunities for attracting and holding these people, once qualified, are increased.

Overall, this bill provides for improved integration and coordination of public health services, with clear lines of accountability, the monitoring of the system's performance by an independent body in a transparent manner and the establishment of various HACs to hold local assets and advise on local community needs, health service issues and important community groups, such as veterans. The Health Care Bill is a comprehensive and an important piece of legislation to ensure that South Australia's public health system has a far better system of governance to meet the increasing and changing demands that are being placed on our health system, and I commend the bill to the council.

Bill read a second time.

Committee Stage

In committee.

Clause 1.

The Hon. J.M.A. LENSINK: The purpose of rising at this juncture is to put the Liberal Party's position in terms of how we will be voting, and also to ask some questions. We clearly did not support the second reading, and we will be calling for a division on the third reading. There are some questions that may have been addressed at clause 58, which is one of the clauses relating to ambulance services, but I am quite happy to put them on the record now.

I would like to reiterate my thanks to officers in the minister's office for providing a further briefing. During that briefing, we talked about non-emergency ambulance services, of which I understand that there are three: the Royal Flying Doctor Service, the State Emergency Service hospital retrieval teams and a service that is provided by Booleroo Centre. There are some rumours in that region that independent licences will not be issued in the future. Booleroo ambulance service has a licence until June 2008, and in the past it has had some difficulty in gaining its licence in a timely manner, and taking up to 12 months to do so. First, will the minister please advise which of those non-emergency services it is intended will be licensed and, secondly, can she give me an assurance that the Booleroo ambulance service will continue to have its licence?

In a separate issue, the Liberal opposition has been approached by a gentleman by the name of David Zammitt, who has long sought to obtain a licence to operate an ambulance service. The organisation's name is WorkCare SA. The Minister for Health stated in an email to him on 30 June 2007, 'Once the proceedings are resolved I will move as expeditiously as possible to finalise the matter.' Here we are in February 2008 and I understand that that has not been resolved. So, if the minister could provide some explanation for the lengthy nature of this matter and whether there are any reasons why that organisation should not receive a licence, I would be very grateful.

Progress reported; committee to sit again.