COMMUNITY HEALTH SERVICES

The Hon. M. PARNELL (17:09): I move:

That this council—

1. Notes:

(a) the review of non-hospital based services currently underway in the SA Department of Health, including the report prepared by internal consultant, Warren McCann, released on 3 December 2012;

(b) the recommendations of the report to significantly reduce community health and health promotion programs within SA Health and the wider community;

(c) the implications, if the recommendations are accepted, to services such as the Shopfront Youth Health Service in Salisbury that has been providing services since 1983;

(d) that these cuts will inevitably lead to reductions in services and programs targeting the most disadvantaged in our society, as it is these South Australians who make the most use of community-based primary healthcare services;

(e) that slashing community health and health promotion programs as a means to reduce government health spending is counterproductive because the whole point of these programs is to prevent ill-health and reduce demand in hospital services where the real growth on costs is occurring;

(f) the risk that these vital services and programs are being caught up in a cost-shifting battle between the state and federal governments; and

2. Calls on the government to reject the recommendations contained in the McCann report into non-hospital based services and ensure continued SA Health funding for vital preventative health and health promotion services and programs.

In August last year, the state government commissioned a review of health services and programs not provided within a hospital setting or that had not been previously reviewed. The purpose was, first, to gain an understanding of the range of metropolitan non-hospital programs currently in place; secondly, assess how effective and productive these programs have been and whether they have helped keep people out of hospital; and, thirdly, identify which programs and services should no longer continue past 30 June 2013. Internal consultant, Warren McCann, was appointed to conduct a review, and he prepared a report that sent a chill through the highly-respected community health sector in South Australia. Warren McCann is recommending that a wrecking ball be sent through community health and health promotion.

Included in the recommendations are defunding of the practice nurse initiative; slashing $2 million over three years and 30 staff from youth primary health services; scrapping completely health promotion services, with a loss of 40 full-time staff; reducing by about a third funding for women's primary health services; defunding residential care health service support; defunding the general practice spirometry lung function service; reducing the funding by nearly half for the program focused on integrated complex care for older people; and reducing funding for the Aboriginal workforce initiative. Not surprisingly, there has been deep concern raised by these recommendations. A public comment period has recently ended, and we now wait for the response to these recommendations from the new Minister for Health.

Members would be aware that a week or so ago a forum was held at the University of South Australia under the title 'McCann of Worms'. Of the people there, what was, I think, universal was that people were unhappy with the recommendations that were made and they were considerably worried about what the impact would be not just on current citizens but also on the long-term future of the health budget. It was pleasing to see that the new health minister, on day two of his job, was at least there to listen to what people said, and I am hoping that he took away a great deal of information.

The review of non-hospital based services report prepared by Mr McCann is a devastating and depressing read. The lack of understanding of the importance of health promotion and prevention in the mix of health services provided by the state government is appalling. South Australia has a very proud history of innovation in community health. Much of this innovation emerged from strong and respectful links with the community and site-specific intervention.

The Greens always welcome service improvements and a focus on value for money in service delivery, yet this review has attempted to narrowly define efficiency and effectiveness in a way that severely limits the ability for health promotion to prove its worth. Health promotion and illness prevention is low-cost, high-impact work. However, much of this positive impact does not flow neatly into quarterly hospital waiting list reduction figures. Chronic illness develops over many years. Preventing these diseases emerging in the first place is always better for the individual and cheaper for society than treating them in a tertiary setting when they are intractable. Yet the benefits of prevention work do not always become apparent in the short term.

This review betrays a highly unsophisticated lack of understanding of population health interventions. The unfortunate title 'Non-hospital based services' is an insight into the low priority given to a population health approach by the instigators of this review. Matching this is an assumption that much of this vital health promotion work will be automatically picked up by the commonwealth through the Medicare Locals service provision model. Without any guarantees, this is a naive assumption in the current political climate.

The recommendations contained within the report, in particular the loss of funding, programs and full-time equivalent staff, are short-sighted and ultimately counterproductive, and they should be rejected. At the very least, we are calling for a 12-month delay in the proposed funding cuts—that is, if the recommendations are accepted by the state government—because that would enable time for the government to negotiate and understand more fully what the commonwealth role will be in this area of health promotion.

I want to talk about some specific concerns, and the first of these is the issue of cost shifting. The implication that a range of health promotion and community health activity will be just 'picked up' by Medicare Locals is questionable to say the least, given that it is very early days for the Medical Locals model and their future past the next federal election is uncertain. The review is clearly a pre-emptive strike in setting a South Australian bargaining position prior to the development of a bilateral agreement on responsibilities for community and public health programs during 2013.

It is poor public policy intervention to firstly be assuming or implying that commonwealth funding via Medicare Locals is really going to take up the cost of community and public health programs and secondly to be pre-emptively cutting programs before any such arrangements have been worked out. The report recommendations are a blatant attempt to cost shift from the state to the federal government. Ordinary South Australians are sick and tired of blame and cost shifting games. They just want a good health service.

The second problem is that there has been very poor use of evidence to attempt to justify these cuts. The evaluation framework created for the review to assess the merit of the programs is dubious on several counts. It uses a very selective reading of current South Australian policy to define three very narrow criteria which almost inevitably health promotion programs will struggle to meet. It applies a standard of evidence for success to many of the target programs that is probably unsuitable, because health promotion programs cannot easily demonstrate evidence on health outcomes in the way a controlled trial of a medical treatment might. It is unrealistic and unfair, given that they have probably never been funded to conduct proper evaluation of their activities anyway.

The programs are being penalised now for foolishly expending their funds on actually delivering the services! In the process of doing this, the report also effectively ignores a wealth of wider evidence on the likely benefits of some of the programs that it is now dismissing as ineffective. The criteria to evaluate the various areas was crafted as a one-size-fits-all model (I refer members to page 13 of the McCann report), yet no rationale is given for choosing an approach that ignores the fact that community based and led intervention are by their very nature community and site specific and therefore difficult to compare.

It is impossible to develop a gold standard randomised control trial to assess the benefits of a community intervention. Absence of evidence, as narrowly defined in this review however, does not mean that these programs are not effective. A cynic would suggest that this evaluation framework has been deliberately designed to create a predetermined outcome.

Next, I believe the review exhibits a lack of understanding of population health. In order for SA Health to deliver quality health outcomes for South Australia, there needs to be a greater focus on health rather than 'illth', yet this is the area recommended for a major reduction in services. Prevention is always better than cure and prevention is heavily dependent on improving the social determinants of health, including access to housing, employment, social equity, transport and a sense of worth. These aspects of society are critical to improving the overall level of health in our state and ultimately producing a long-term reduction in the costs of providing health services to the community.

There is a wealth of evidence here and overseas that the most successful and positive impact on population health comes not from top-down provision by health services but an integrated relationship between expert health workers and the community they are embedded within. People are not neat boxes to be ticked, and pursuing population-wide health improvements, especially with vulnerable and marginal members of society, requires a willingness to go beyond a one-size-fits-all approach. Yet these cuts will inevitably lead to reductions in services and programs targeting the most disadvantaged in our society.

It is the people at the margins, the poor and the vulnerable, who make the most use of community based primary healthcare services. They will be the ones who will be the hardest hit, with the negative impact cascading through other parts of government focused on housing and community services. For example, there are reports that the Shopfront Youth Health clinic in Salisbury, a service that was established with the local council 30 years ago, may be axed as a result of these recommendations. It is simply impossible to evaluate, using the criteria in this review, how important this service has been for the Salisbury community.

The Shopfront clinic on John Street, which provides a walk-in service to people aged 12 to 25 is the basis of this service. Since 1983 it has helped vulnerable young people in Salisbury battling mental health and drug and alcohol issues, providing a crucial first point of contact for vulnerable youth with other services, such as needle exchange programs, lawyers and counselling. Under the McCann recommendations, a new youth health clinic would be opened in the northern suburbs to replace Shopfront.

However, this new clinic would only treat youths aged between 12 and 19 and focus on targeted groups, such as wards of the state, Aboriginal youth and those in youth training centres. This is an enormous risk that many young people, currently served, will simply fall through the cracks. I also believe that many of these recommendations are genuinely counterproductive and one of the most frustrating aspects of this report is that the results will, in fact, be the exact opposite of what is intended.

The intent of this review is to find cost savings. Yet, if implemented, the most likely outcome of these recommendations will be an increase in costs. It is always much cheaper to prevent the onset of chronic disease than treat the disease once it is severely impacting on an individual. For example, slowing the progression of just one person's diabetes and delaying their commencement on renal dialysis by one year saves the health system upwards of $70,000. That is one person saving for one year.

South Australia has the highest rate of obesity in Australia and one of the highest in the world. Yet this review recommends the slashing of community nutrition programs. If such recommendations are put into action, programs like the statewide peer nutrition Community Foodies program will disappear at a time when overweight and obesity rates are of major concern and predicted to lead to huge increases in costs for the health system. The whole point of such programs is to prevent ill-health and reduce demand in hospital services where the real growth on costs is occurring.

In addition, the cuts and restructuring recommended will mean a significant loss of worker capacity in this field. The proposed cuts will also likely equate to a loss of valuable infrastructure and knowledgeable, passionate personnel who have established good relations with their local communities. There will be marginal savings at best. Health promotion is a tiny fraction of the total health budget. The targeted saving of $14 million per annum is tiny and insignificant compared to the current growth of public hospital costs. It is bizarre for such a focus on a relatively minor saving when other costs, such as the significant increase in specialist's salaries or the ongoing issue of waste disposal, remain largely unaddressed.

The review is heading in the wrong direction. It is a symptom of a broader governance problem beyond SA health and that is of short-termism or passing on current costs to the next generation. The Greens fully acknowledge that there is an urgent need to tackle the year-on-year increase in health costs which currently are forecast to overwhelm the total South Australian budget in around 20 years if growth rates continue. But this review is completely the wrong approach. The loss of health promotion and wellbeing programs will merely provide short-term budget gains at the expense of long-term increases in demand for acute care services.

The austerity measures in this report are also not fairly shared. Professor Baum, Director of the Southgate Institute for Health, Society and Equity at Flinders University, has been very vocal in raising her concerns. She also facilitated the 'McCann of Worms' public meeting at the university. Here is an excerpt from a piece that she wrote recently entitled 'Cutting disease prevention and health promotion won't reduce health spending'. Professor Baum's article states:

If we want to stem the costs of health care we have to increase investment in community services and reduce the amount spent on hospitals.

In the past five years the salaries and payments to medical specialists have increased very significantly.

Far more could be achieved if McCann had been asked to systematically document these increases and shown the community that their much valued local health services were being lost because medical specialists have received considerable pay increases.

This is the community conversation that we need to have. Otherwise it is austerity for some and not for others. Ironically the cuts McCann recommends will affect the most disadvantaged of South Australia's community because of salary increases for our most advantaged!

Finally, it was an irony that the McCann report was released when the Southgate Institute—

which is where Professor Fran Baum works—

was being visited by Professor Ron Labonte from the University of Ottawa.

He reminded us that the current austerity sweeping the world results from political decisions to bail out banks and from the increasing concentration of wealth. He also reminded us that we collect significantly less taxation as a percentage of GDP than we did 20 years ago.

Imagine a world in which McCann put his considerable economic skills to work to determine how much extra tax we could collect from the super-rich who use tax havens, and from corporations who have an army of taxation experts to help them reduce their taxation.

Then we could look forward to a McCann report that calls for increased investment in health promotion and community health on the grounds that prevention is cheaper than cure!'

In conclusion, we have to stop kicking the can along the road and start tackling the reasons South Australians are getting sick in the first place. Building healthy communities now is the best possible way to ensure healthy communities in the future. The first step is to reject any scaling back of the health programs and staff focused on doing just that. The Greens strongly urge the government not to accept these short-sighted recommendations. The deeply concerning thing is that other health promotion programs not reviewed under this system may soon also be under attack if this approach is allowed to proceed here.

At the end of the day, pouring all of our limited health resources into emergency care and complicated repair work will mean that we will never be able to control spiralling costs as the demand for services will just keep growing. We must start focusing instead on keeping South Australians healthy. The McCann recommendations must be rejected.

Debate adjourned on motion of Hon. T.J. Stephens.