Bills

Health Care (Administration) Amendment Bill

Second Reading

Adjourned debate on second reading.

(Continued from 8 September 2015.)

The Hon. J.A. DARLEY (15:24): I rise to speak very briefly on the Health Care (Administration) Amendment Bill, and to echo some of the comments of other honourable members. As has been noted, this is the third time we have had this bill before this parliament, and I have to agree with my colleague the Hon. Dennis Hood that it is certainly a good example of why we do not need such frequent prorogations.

In the main, the bill deals with fees for services provided by the SA Ambulance Service that do not involve ambulance transport and employment arrangements for doctors, nurses and midwives within the Department for Health and Ageing. There are, of course, some other technical amendments incorporated into the bill, but it is these two aspects in particular that have been the focus of most attention. I certainly share the concerns raised by other honourable members in relation to these two aspects of the bill, and, in particular, concerns about the potential for increased costs to rural patients as result of changes to fees.

For the record, whilst I support the second reading of the bill I will certainly be paying attention to the explanations provided by the government on these issues, and also to the responses by the government on specific issues and questions raised by the Hon. Stephen Wade.

The Hon. G.A. KANDELAARS (15:26): I rise in support of this bill, and in doing so will address the benefits for the community of incidental services, usually called Treat no Transport services, provided by the SA Ambulance Service.

The purpose of the proposed change is to simplify the mechanism for setting fees for Treat no Transport services provided by the SA Ambulance Service, one of which will align with the current mechanism for setting fees and charges within the Health Care Act 2008 for both hospital services and ambulance services. Apart from the fee for Treat no Transport services, all other ambulance fees are covered by section 59 in the act.

Under the current regulations and the proposed amendment in the bill, an incidental SAAS service is provided if:

a member of the staff of SAAS attends at a place in response to a request for medical assistance, whether made by a 000 emergency telephone call or other means, for a person who may have an injury or illness requiring immediate medical attention in order to maintain life or to alleviate suffering; and

the SAAS staff member assesses or treats the person; but

the person is not transported by ambulance.

Section 59 allows the minister to fix fees for ambulance services from time to time in the Gazette. Ambulance services are defined under section 3 of the Health Care Act 2008 as follows:

'Ambulance service' means the service of transporting by the use of an ambulance a person to a hospital or other place to receive medical treatment or from a hospital or other place at which the person has received medical treatment.

This definition reflected a traditional ambulance model and did not take into account incidental services that do not involve transport. Consequently, the Fees Regulations (Incidental SAAS Services) Regulations 2009 were made under the Fees Regulations Act 1927 to provide for incidental services' fees as an interim measure. It was intended to fix this anomaly at the first available opportunity so that all fees were in one place, namely the Health Care Act 2008.

Clause 7 of the bill, which will amend section 59(1) of the Health Care Act 2008, will allow the charging of fees for incidental services—that is, the Treat no Transport services—but it will also allow for other matters to be prescribed by the regulations. This additional provision will give greater flexibility to the SA Ambulance Service for fee setting into the future should new models of service provision develop. New technologies are already emerging that may transform the way ambulance services, as first responders, respond to patients' future needs.

The amendment is an administrative change only. It does not affect or make any changes to current SA Ambulance Service practices or services. It will have no impact on the services provided to the public by the SA Ambulance Service. The amendment merely switches the legislative mechanism for the setting of a fee for incidental services from the Fees Regulations (Incidental SAAS Services) Regulations 2009 to the Health Care Act 2008.

The current regulations make it a requirement that the SA Ambulance Service will provide a service consequent to a 000 emergency telephone call or other means for a person who may have an injury or illness requiring immediate medical attention in order to maintain life or to alleviate suffering. This requirement will continue. A decision treat at the patient's residence and not transport, or to treat and transport to a hospital emergency department will always be based on the patient's medical needs as determined by the attending SA Ambulance Service clinicians.

There has been a positive impact on the community in having different ambulance service options available, including the Treat no Transport service. These treatment options ensure better care for the community and greater efficiency and effectiveness of ambulance services. For example, providing care for and treating people in residential aged care has been shown to provide better health outcomes.

Unless hospital care is needed, treating people in their residential aged-care home and keeping them out of hospital is often a much better option because it means less disruption, less patient confusion and earlier return to normal health in familiar, supportive and comfortable surroundings. Patients can also receive more tailored care and, if needed, this care can be managed in collaboration with other health professionals.

Significant changes to the scope of work and practice of ambulance services are occurring in SAAS. The SAAS Strategic Plan outlines various strategies to better use the skills of paramedics and ambulance services. For example, one area of focus is integrating ambulance services within the broader health system by developing better strategies for managing health care needs of people who do not need emergency transport to a hospital but who do need care.

Another strategy is to increase capacity to respond quickly and at greater speed. The SA Ambulance Service has introduced ambulance single responders in cars, motor bikes and bicycles so that treatment can be instigated sooner and faster in any given conditions. Earlier intervention can reduce the extent of damage caused by injury or illness and can also facilitate faster recovery, reducing hospital length of stay.

The extended care paramedic (ECP) service allows patients to be treated at home or in their home surrounds, without being transported to a hospital emergency department if it is not necessary. An ECP is an SA Ambulance Service intensive care paramedic who has undergone intensive skills enhancement and training. ECPs can treat patients for a range of common medical issues and refer them to other health providers such as GPs, if necessary. The Treat no Transport fee is a low cost, affordable fee for a service that can give peace of mind to the community and achieve better outcomes, especially for seniors.

As of 1 July 2015, the incidental SAAS fee—the Treat no Transport fee—is a flat rate fee of $200, and for holders of a valid prescribed card the fee is $101. I understand that people who subscribe to the SA Ambulance Service's cover product are covered for the cost of all ambulance services provided by the SA Ambulance Service, including Treat no Transport services. Subscribing to the SA Ambulance Service's ambulance cover product is something that every person should consider given its low cost and good value.

Whilst this amendment is administrative, it signifies the potential for further innovation in line with emerging international trends for ambulance service delivery to provide the right care in the right time. I commend the bill to the chamber.

The Hon. T.T. NGO (15:36): I also rise to speak in support of the Health Care (Administration) Amendment Bill 2015. This bill will make technical amendments to the Health Care Act 2008. I would like to focus on staffing arrangements for medical officers, nurses and midwives within the South Australian Department for Health and Ageing or SA Health Central Office. The bill inserts a new section into the Health Care Act 2008, namely, section 89—Other Staffing Arrangements. The intention of this section is to remedy a longstanding technical issue that was largely an unintentional consequence of the passage of the Health Care Act 2008.

The Health Care Act 2008 repealed the South Australian Health Commission Act 1976. Under the South Australian Health Commission Act 1976, the administration and management of all health services, including the employment of all staff within the state, was undertaken by the statutory authority. When the Health Care Act 2008 came into effect, administrative and allied health professionals working in the department came under the employment arrangements of the Public Sector Act 2009.

In establishing the mechanisms for employment of staff under the act, it was thought at the time that medical, nursing and midwifery officers would be employed in the department pursuant to the professional awards under section 34 of the Health Care Act 2008. Section 34 is under part 5 of the act which deals with the incorporated hospitals and their management arrangements. I understand that the purpose of engagement of staff under section 34 was to facilitate the functions of an incorporated hospital. However, the department is an administrative unit for the purposes of the Public Sector Act 2009 and therefore medical officers, nurses and midwives would need to be employment under this latter act.

The department employs medical officers who may be employed as public health medical practitioners or medical administrators. It also employs nurses and midwives who may undertake public health and nursing administrative roles. All clinicians undertake profession-related clinical advisory functions which are essential to the department's role in the state public health protection and health service provision. For example, nurses are employed in overseeing the management of vaccine services across the state. They also provide advice to community-based general practitioners, community immunisation nurses, as well as other health professionals on the National Immunisation Program schedule.

They also provide advice on the Australian Immunisation Handbook which outlines standards for safe and effective use of vaccines. These nurses are responsible for the state's immunisation program and making sure vaccine is distributed where it is needed. They also support the rollout of vaccination programs in schools as well as ensuring consistent and appropriate vaccine practices across public and private health systems.

Medical officers and nurses are employed in communicable disease control. These clinicians ensure the public health protection requirements, set out in the South Australian Public Health Act 2011, regarding notifiable and controlled notifiable conditions are met. They monitor and respond to any notifiable conditions that are reported to ensure that timely intervention is provided to protect public health.

I understand there were two options for establishing an appropriate employment arrangement under the act for medical officers, nurses and midwives. One option was to bring them under the Public Sector Act 2009 and its associated instruments, such as the South Australian Public Sector Salaried Interim Award and the South Australian Public Sector Wages Parity Enterprise Agreement: Salaried 2014, none of which recognises the qualifications, entitlements and continuing professional development requirements for clinicians. Whilst it was possible to employ clinicians under the Public Sector Act 2009, it would have meant there would have been some delays and difficulties in enabling the accreditation, registration and continuing education requirements that their current awards enshrine.

The second, preferred approach, which is the one before us in the bill, is the proposed insertion of section 89 into the Health Care Act 2008 contained in clause 8 of the bill. This preferred approach is similar to the mechanisms used by the Department for Education and Child Development to employ teachers within that department pursuant to their professional award under section 101B of the Education Act 1972.

This better mechanism enables clinicians to be employed within the Department for Health and Ageing under their professional awards. It ensures all professional requirements, such as recognition of qualifications for registration under the National Health Practitioner Regulation National Law (South Australia) Act 2010, continuing professional development and other requirements for clinicians, are appropriately recognised and assured just as they are for clinicians employed in our hospitals and other health services. There are no changes to the conditions of employment and all entitlements will continue unchanged.

It will be important to note that clause 89(1) sets out that the employing authority may appoint such other officers or employees who have skills or experience in connection with the provision of health services and who can assist the chief executive and the department in the performance of their respective functions. The term 'health services' used within this clause is defined under the Health Care Act 2008. The term 'health services' pertains to this definition and has no other intent but to describe where persons may work. It does not capture other types of employees under section 89. All other professions, such as allied health staff employed within the department, are employed under the Public Sector Act 2009 and are, therefore, unaffected by this new clause.

I understand that the representatives of medical officers, nurses and midwives, namely, the South Australian Salaried Medical Officers Association (SASMOA) and the Australian Nursing and Midwifery Federation (SA Branch) (ANMF) were consulted about this proposed change. They indicted that, provided there were no changes to the conditions of employment, the amendments were supported. As I understand it, this is simply a technical matter and there is no likelihood that any employee's conditions would be affected by these amendments. Indeed, it gives full recognition to the conditions of employment under their awards. I commend this bill to the house.

The Hon. I.K. HUNTER (Minister for Sustainability, Environment and Conservation, Minister for Water and the River Murray, Minister for Climate Change) (15:44): I apologise for being so slow to rise to my feet, but I have been mesmerised by the contributions from the Hon. Mr Kandelaars and the Hon. Mr Ngo. The depth of understanding evinced by their contributions, the remarkable clarity and the comprehensive nature of their understanding of this legislation really has encompassed a lot of the questions that were put on the record to be answered during the second reading closing speech. I will, however, soldier on to give the ministerial imprimatur to the explanations in a somewhat more brief way than we have just heard. Again, the depth of understanding is incredibly commendable and I commend both honourable members for their contributions.

The Health Care (Administration) Amendment Bill 2015 makes a number of technical amendments to the Health Care Act 2008. They include provisions which will allow the following:

Fees for services provided by the SA Ambulance Service that do not involve transportation in an ambulance—that is, the Treat no Transport services—to be set through the Health Care Act rather than the Fees Regulation Act.

Provide a mechanism for the employment of medical practitioners, nurses and midwives in the Department for Health and Ageing (i.e. the central office).

Dissolution of three non-operational incorporated associations and the formal transfer of their assets to the appropriate health advisory council. This is a longstanding issue that requires resolution, I am advised.

Amendments to be made to section 29(1)(b) of the Health Care Act 2008 so that it is clear that a specified person or body does not need to be providing services and facilities to an incorporated hospital for the business or operations of that body to be transferred to that incorporated hospital.

The Governor, on application from the minister, to make a proclamation to transfer the assets, the liabilities and the undertakings from one incorporated hospital to another without the incorporated hospital to which these first belonged having to be dissolved, which I understand is the current requirement.

Removing section 49(5) of the act that allows the minister to determine the constitution for the SA Ambulance Service. The functions and powers of the SA Ambulance Service are already set out in the act, I am advised. I am also advised that a constitution has never been determined and so is not required for the effective functioning of the SAAS.

An amendment to ensure the SAAS staff and medical practitioners, nurses and midwives to be employed under the new section 89 are covered by the conflict of interest provisions.

An amendment to clarify terminology used in section 93(3) of the act so as to limit disclosures of information required under this section to disclosures that are required or authorised by, or under law to reflect more accurately when and how legal disclosures of information may be made.

An amendment to add the term 'substitute decision maker' to their list of persons who may request or provide consent for information about a person to be released so that the wording aligns with the provisions of the Advance Care Directives Act 2013.

Transitional provisions regarding the continuity of employment and conditions of employment of medical practitioners, nurses and midwives into the central office.

Transitional provisions regarding the cancellation of the incorporation of certain associations.

I am advised that these are technical issues that will improve the operation of the act. Turning to the questions of the Hon. Mr Wade, I note his concerns about the slight wording change in the bill of the definition of 'incidental services' from that which is in the Fees Regulation (Incidental SAAS Services) Regulations 2009. My advice is this: the wording change primarily concerns the inclusion of the words 'attends at a place in response to a request for medical assistance' instead of 'responds to a request for medical assistance', as is currently set out in the Fees Regulation (Incidental SAAS Services) Regulations 2009.

The words set out in the bill as such make it clear that it would exclude a service that may involve telephone advice or a person receiving treatment at a community event, for example, where SAAS might be in attendance already. It makes it clear that there must be a physical attendance at another place; that is the intent behind the slight change.

In relation to the inclusion of a regulation-making power, this provides the minister with a flexibility to introduce a new fee, should this be needed, for example, if a new service model was developed and it needed a specific fee to be established. If a new fee were to be introduced, this fee, of course, would be disallowed should the parliament find it unnecessary or unconscionable, as is general practice now.

The honourable member also indicated a concern about the breadth of the wording in clause 8, proposing a new section 89. My advice is that this wording is consistent with the definition of health services within the act and the range of activities that may be undertaken by the professionals concerned.

There was a further query as to whether the professional skills would necessarily be used by staff in all of the areas listed on the table. My advice is that that is not the case. Hospitals and health services are complex systems, of course, and professional skills include both clinical skills for direct service delivery and knowledge about clinical service structures and systems that are needed for delivering and improving health care. Areas such as information systems and industrial issues, for example, also require professional knowledge.

The other, and I think final, question was whether the individuals identified in the table would be impacted by these changes. My advice is that they will not be impacted at all. Their conditions and entitlements continue and the bill ensures this through the transitional provisions.

The Hon. Dennis Hood and, I think, the Hon. John Darley in his contribution, indicated their concern about the possible costs for rural patients using the ambulance services under this bill. Again, I think the Hon. Mr Kandelaars addressed this quite comprehensively. In the case of the treat no transport ambulance fees, there will be no effect, is my advice.

Firstly, the bill will simply change the legal mechanism for enabling these fees to be set to one that is aligned with the setting of all other fees under the Health Care Act 2008. Secondly, the treat no transport service potentially increases access to more treatment options for rural patients, while reducing costs if transport is not needed.

For example—and I think again the Hon. Mr Kandelaars went into this detail—the fee for an ambulance emergency callout requiring transport is $918 currently and there is a mileage cost that is additional to this. However, the flat fare for no transport attendance is $200 and so it can be seen that there is a clear advantage for rural patients in being able to access these services in rural areas, not discounting the benefits of not suffering the disruption to their lives from having to go elsewhere for treatment and care.

The SA Ambulance Service's Strategic Plan, Defining the Road Ahead, outlines a framework for service delivery models that aims to meet increasing demand for ambulance services as well as the changing needs of the community. Providing alternative tailored health service options with a better capacity to treat more patients in their own home and the near surrounds in addition to the traditional ambulance model where patients must be transported to a hospital emergency service or department means extraordinary service gains for the patients, the community and for the SA Ambulance Service.

I am deeply appreciative of the indications of support for the bill by the Hon. Mr Wade, the Hon. Dennis Hood, the Hon. Kelly Vincent, the Hon. John Darley and the Hon. Tammy Franks, especially since, as the Hon. Tammy Franks mentioned in her contribution, this bill has been in the unfortunate position of having been prorogued twice. I endorse Ms Franks' hopes and aspirations that this third time will be a charm. I commend the bill.

Bill read a second time.

Committee Stage

In committee.

Clause 1.

The Hon. S.G. WADE: I was hoping to ask some questions at clause 1. I would like to thank the minister for the responses to questions provided. In terms of the flexibility for a new fee that he refers to that is in relation to the proposed section 59(1)(c), is the government or the South Australian Ambulance Service currently considering any proposal which would involve a new fee?

The Hon. I.K. HUNTER: My advice is no.

The Hon. S.G. WADE: I would like to turn now to the table which I inserted into Hansard which was provided to me following a briefing. Before I do so, I might apologise for my mathematics on the run where I think I suggested that in terms of volume and billing value that the increase had been about 20-fold when, in fact, having employed the services of a calculator, I can clarify that what the briefing suggests is that in the last five full calendar years the increase in volume of incidental services has been 15-fold.

The Hon. I.K. Hunter interjecting:

The Hon. S.G. WADE: You will never be Treasurer because that was volume, not value. Let's turn to value so the minister can try his luck at being Treasurer.

The ACTING CHAIR (Hon. J.S.L. Dawkins): Surely, the honourable member will be uninterrupted by the minister.

The Hon. S.G. WADE: In relation to billing value—and this is where the dollar signs come in, minister—there is a 19-fold increase in billing value and he may well speculate that that is an increase in nominal terms, but that is not really my point. My point is: whether it is 15-fold or 19-fold, in five years that is a very significant increase. Can the minister please explain why there has been such a large increase in incidental services in the last five calendar years?

The Hon. I.K. HUNTER: To boil down the answer into simple terms so that I can understand it, my understanding is that this is a response to volume and demand. So, rather than services themselves increasing in the order the honourable member has indicated, it is actually a volumetric approach that more people are demanding these services—for example, extended care programs and ambulance programs. If you look at it from a helicopter view, providing further services in these areas means that overall for health services there will be significant, hopefully, savings and the costs to the system overall will be somewhat less.

The Hon. S.G. WADE: Is the minister suggesting that demand for SAAS services beyond the incidental area would have increased by a similar amount? Are we talking about service-wide demand increases and, if we are not, why has this area increased in a way that the rest of the service has not?

The Hon. I.K. HUNTER: My advice is that demand for overall services has increased generally, although I do not have the figures before me to be able to break that down in terms of different areas of the health service, but the service provision has been increasing as well and it is a function, as I mentioned earlier, of overall demand in terms of volume. This is, in particular, a niche service for out-of-hospital care and particularly in relation to home or, indeed, even possibly a nursing home or residential care of some sort, so the demand on this has been significantly higher, but, as I said, I don't have the figures in front of me to confirm the honourable member's expected increase.

The Hon. S.G. WADE: Considering that in the five calendar years that we are looking at we had things like the Monaghan review on emergency ramping at the Flinders Medical Centre—that was four years ago, so it is very much part of this same period—can the minister assure the house that part of the increase in the demand is not the ambulance service responding to stress at emergency departments by providing services in place because of a lack of capacity in the emergency departments?

The Hon. I.K. HUNTER: My advice is there is no substitution of services here in this issue. All decisions are taken based on the medical and clinical assessment needs of the patient, and it would be inappropriate to make a determination to substitute services not in the interests of the patient. I am further advised that the triaging processes are very clear and applied with the appropriate oversight so that there is no substitution of services—I think the member was alluding to ambulance services, i.e. ramping vis-a-vis other services—in the interior of the hospital.

The Hon. S.G. WADE: If I could go back to the table and the use of the column called Volume, I am presuming that 'volume' refers to the number of individual services delivered. Could the minister confirm that?

The Hon. I.K. HUNTER: My advice is that it is in direct response to the volume of staff. As the extended care paramedic program has grown over this period, so the number of paramedic or staff employed has extended to care paramedics, and that is the nature of the expansion.

The Hon. S.G. WADE: I am sorry, minister, I obviously have not made myself clear enough. Perhaps I could ask my two questions and then it might be clearer. I do not know whether 'volume' refers to the number of patients who receive services, and therefore every episode of Treat no Transport is one patient one incident, or whether one call-out for a Treat no Transport from an ambulance might actually lead to two or three services; therefore, I hope that question is clearer.

The Hon. I.K. HUNTER: My advice is (and this is a surprisingly difficult question) that the table that was applied was based on the understanding of the Hon. Mr Wade's original question. Should he want to interrogate that further by getting clarity about whether it is actually the number of patients or number of call outs versus number of services, that data will have to be interrogated again. We have no problem with doing that for the honourable member, but I will not be able to supply the information today.

The Hon. S.G. WADE: I thank the minister for his undertaking to take that on notice, and I would be happy to do that post the progress of the bill.

Clause passed.

Remaining clauses (2 to10), schedule and title passed.

Bill reported without amendment.

Third Reading

The Hon. I.K. HUNTER (Minister for Sustainability, Environment and Conservation, Minister for Water and the River Murray, Minister for Climate Change) (16:06): I move:

That this bill be now read a third time.

Bill read a third time and passed.