Parliamentary Committees

Select Committee on Transforming Health

The Hon. S.G. WADE (20:25): I move:

That the final report of the select committee be noted.

In seeking to note the report, I would like to turn to comments made only yesterday by the Minister for Health in this place. In answer to a question completely unrelated to Transforming Health, the minister asserted (when he uses the word 'we' here, he is referring to the Weatherill Labor government):

We are serious about taking on board clinical advice, whether it be at The QEH, whether it be at the RAH, whether it be at the Modbury Hospital, and that is why our health policy will be cogent, methodical and based on evidence and advice, because we want to make sure people get the health care they deserve.

I almost felt as though the minister was channelling the rhetoric of Transforming Health. It reminded me of a quote that the Select Committee on Transforming Health included in its fifth interim report. In that report, the committee referred to evidence given to the committee on 10 March 2017 by Professor Dorothy Keefe, the clinical ambassador for Transforming Health. She summarised some of Transforming Health's changes in the following terms:

Transforming Health has resulted so far in a major infrastructure and human resource investment, leading to evidence-based realignment of services that has enabled implementation of the clinician-led, patient-centred, evidence-based, contemporary models of care to ensure that South Australia has a health system that embraces innovation, takes full advantage of technology, implements advances in medical treatment and is flexible in meeting the challenges of the future to maintain the patients at the centre of everything we do.

That was almost like a daisy chain of rhetoric, and that was what Transforming Health was characterised by.

The Hon. T.A. Franks: Welcome to Utopia.

The Hon. S.G. WADE: Welcome to Utopia. Professor Keefe and other ambassadors for Transforming Health—and for that matter, let us be clear, minister Snelling before minister Malinauskas—repeatedly claimed that 95 per cent of clinicians supported Transforming Health. What a lie! What 95 per cent of clinicians said, in a very early survey in this process, was that they supported the principles of health reform. That was taken and twisted and repeated time and time again. It was not true, but it was used as propaganda by this government. I believe it was a wanton misstatement of the clinical consensus in this state.

For those who have not been watching the calendar as closely as I have, today is 29 November. Yesterday was 28 November, three years to the day since the Adelaide Convention Centre was hired by this government for what they called a summit on Transforming Health. At this summit—and to be frank, I was there—there were hundreds of people who were listening to almost Amway style presentations from minister Snelling and other members of the SA Health crew. It became almost like, as I said, Amway, a cult-like approach to health reform.

Minister Malinauskas yesterday suggested that he and this government were committed to clinician-led reform and that we could see that at The QEH, at the RAH and at Modbury. So let us look. Let me look at each of those in turn, and so that the President might be assured that I stay within the terms of this motion, I will do that by referencing different reports of this select committee. Again, the minister is asserting that this government respects clinical advice, that what it does is evidence-based and clinician-led—absolute rubbish! Let's look at The QEH. This is the third interim report of the select committee, and I quote, page 26:

Throughout the inquiry, witnesses recounted their interactions with SA Health in highlighting many concerns about the department's consultation approach. Inquiry witnesses criticised the plan to move rehabilitation services to the QEH without genuine community consultation. Some senior clinicians also complained about the lack of transparency in the decision making process, and expressed concern about the limited availability of information regarding the proposed changes directly affecting their clinical areas.

The committee, later in the report at page 28, highlighted some of the personal experiences of senior clinicians, senior clinicians who were not leading the process but were being disrespected by the process. At page 28 it states:

Many clinicians who provided evidence were highly critical of the Government's consultation approach, with some telling the inquiry they have gained more information about changes to rehabilitation services from reading their local Messenger newspaper.

Let me quote:

We attempted to engage and consult with management in Transforming Health, but there was no reciprocation, so we actually got the rest of the information from the Portside Messenger.

Another senior clinician described his initial reaction, upon learning about the dislocation of the respiratory ward through the local newspaper:

[It] makes you feel a bit low to pick up the Messenger press in your driveway to find that, despite claims of extensive consultation…that none of us actually received, [to learn that] your ward and your high dependency bays are now a dining room for Hampstead patients being transferred. It's disappointing because we actually had heard this might be happening and attempted to talk to the [Chief Executive Officer] at the time and various other administrators, who basically declined to discuss it.

Dr Jelbart, who is a highly-respected clinician in the area of rehabilitation told an inquiry that:

…that staff from the brain injury service were 'specifically prevented by Transforming Health from visiting the proposed site to better understand the space and constraints [the service] faced in design'. The reason for this such exclusion was because staff from other clinical areas, such as geriatrics, respiratory and palliative care, that were directly affected by the changes 'had not yet been informed that they would be…evicted in favour of our clinical services'.

Dr Jelbart went on to say that staff were 'specifically instructed not to discuss this matter with any QEH clinical staff'.

This is not clinician-led reform based on sound clinician consultation. Do you see what is happening here? You have the people from Hampstead, who want to make sure that their clients in the new QEH facility are going to get the services they need: 'No, you can't go and look at The QEH, because that might tip off the people we are going to evict, and the people who are going to be evicted can't be informed because they might get grumpy about the change.' This is not clinician engagement, clinician-led reform: it is deceitful spin for the government to perpetuate this rhetoric.

Let us be clear, the committee's report was tabled on 8 June 2016, so the government has had the chance to mend its ways. It had a third interim report, which highlighted the concerns about the lack of consultation. In that committee report the committee found that the government's planning and consultation processes have been seriously deficient. It states:

Evidence from consumer groups and senior clinicians consistently reported that the consultation process regarding the proposed changes to rehabilitation services under Transforming Health had been characterised by predetermined outcomes, a culture of secrecy and a lack of openness and transparency.

This approach is disrespectful to both consumers and clinicians, and likely to not produce the best possible outcomes.

So, that is The QEH. The minister says, 'You can see our clinician-led reform at the RAH.' Let me turn to the evidence given to the committee on 10 February 2017 by Professor Paul Reynolds, the chair of the Medical Staff Society at the Royal Adelaide Hospital. Let's be clear: this is not the porter, this is not the union rep, this is Professor Paul Reynolds, the chair of the Medical Staff Society, and this is what he told the committee about his engagement with the new Royal Adelaide Hospital.

The minister wants to tell us that this is clinician-led reform with clinician consultation. Well, what was Professor Paul Reynolds' experience? He highlighted in his evidence before the committee that the views of clinicians shared during consultation were not acted upon. He said, for example:

I have been involved in planning committees ever since day one when what was the Marjorie Jackson-Nelson Hospital was first announced. I have been on a number of committees and I think one of the frustrations we have all had is that it is a bit like groundhog day. We are starting the process again repeatedly. Whilst there is a lot of talk about clinical consultation, I think the reality is that whilst there have been meetings, the outcomes of these meetings have often not led to much and the views of clinicians may have been recorded but not ever particularly actioned upon.

He talked about the chaotic planning and consultation and the fact that clinicians receive no feedback:

The floor space of the new Royal Adelaide has been known for probably four years, so all of this scramble to get the outpatient services planned should have been happening gradually over those years and not be a mad rush in the last few months.

Professor Reynolds was talking about a document that was provided in August 2016 as part of consultation. He said:

That document was provided back in August [2016] in response to a consultation paper and now, some six months later, we have had no formal feedback…

So, here we are. We are supposed to be in the hospital by now, but even the Medical Staff Society raises issues and six months later has no formal feedback. Again, quoting:

Again, I bring this up repeatedly in committee meetings, and I am told that it's on its way. That is yet another example of the inadequacies of the consultation process.

Professor Reynolds, before the committee, talked about clinical advice just being ignored:

I sat in on some of the planning meetings, probably six years ago, when they were drawing up the floor plans, and I made points at the time, as did my colleagues, that we needed more waiting areas in certain places. We expressed concerns about things. But these opinions were largely ignored.

Feedback on consultation was not good and lip service was being paid to clinicians' concerns. Professor Reynolds talked about the problems that ensued at the closure of Ward S7. There was a feedback document, apparently, that was circulated, but the feedback was due on 23 December, two days before Christmas. Yet, in spite of that, by the first week of January, a frequently asked questions response was circulated, which did not reflect the negative concerns of the medical personnel. Professor Reynolds stated:

So it wasn't exactly consultation: it was more like a pronouncement and then lip service paid to a consultation process. Again, that has been our experience.

Minister Malinauskas wants to tell us that The QEH was based on clinician-led reform and that the RAH was based on clinician-led reform. That is not what the clinicians told this committee. He also suggests that there was clinician-led reform at Modbury. Let's look at the Fourth Interim Report of the Select Committee on Transforming Health and its comments in relation to Modbury. Dr Jackie Davidson, the head of the emergency department at the Modbury Hospital, was critical of the government's consultation process, specifically as it relates to NAHLN. She told the committee that the process was either extremely rushed or sometimes ignored.

Dr Davidson said it was wrong for the government to claim that extensive clinician engagement had occurred as part of the consultation process. Dr Davidson expressed concern that the government's strategy of distributing generic emails that contained little more than broad ideas was insufficient to engage clinicians in a meaningful way. She went on to tell the committee that when more detailed information about the plans was provided to senior clinicians, their concerns were elevated and they felt unable to support the proposed changes:

The proposals circulated in 2015, the Transforming Health proposals, were too generic to give meaningful feedback. They were more ideas, you know, 'Modbury will be the rehab centre', 'Modbury will focus on elective surgery'. Once we had a more detailed service plan circulated, which was February 2016—

a year later—

the feedback given by 31 Modbury specialists, that included five heads of unit, was that not only did they feel unable to support the proposals but the proposals were against all six of the quality healthcare principles endorsed by Transforming Health, those being patient-centred care that is safe, effective, accessible, efficient and equitable.

Did the government change any of this? Is this clinician-led reform? Is this clinician engagement which is leading to evidence-based outcomes? None of that changed, and now we have the new minister running a PR campaign to try to defend the Transforming Health downgrades. This was not clinician-led reform in its foundation, nor will it be in its defence.

The minister raised, as I said, three examples: Modbury, The QEH and the RAH. I believe the work of our committee shows that he is misleading this house if he was to suggest that that was clinician-led reform. But do not take my word for it; do not take the committee's word for it; let us look at what the AMA and SASMOA, the two key doctors representation bodies in South Australia and, as I understand it, the only health professional representative bodies who have done surveys, found when they asked their members.

The committee received a copy of a survey of doctors and final year medical students jointly undertaken by the AMA and SASMOA. The survey of 530 doctors was published in April 2016 and showed broad opposition to reforms under Transforming Health. No; it is not clinician led. It is not clinician informed. It is government propaganda.

Among the findings of the survey were the following: over 60 per cent disagreed or strongly disagreed that Transforming Health will provide better care for patients. Over 70 per cent of those surveyed did not believe that Transforming Health will deliver best care first time every time to all South Australians. Around 80 per cent disagreed or strongly disagreed that the government had conducted effective stakeholder consultation during the implementation of Transforming Health, and around 88 per cent of the survey respondents felt they did not have an ability to influence the outcomes with regard to the implementation of Transforming Health.

How can it be clinician led when 88 per cent of such a key group of clinicians do not believe they can influence the process?

The Hon. T.A. Franks: You pay somebody else to spruik it for you.

The Hon. S.G. WADE: As the Hon. Tammy Franks interjected, they paid somebody to spruik it for them.

The PRESIDENT: Maybe the Hon. Ms Franks should not interject and let you get on with your speech.

The Hon. S.G. WADE: It was a very apposite interjection, I must admit. The committee heard that as a result of inadequate and hasty consultation, morale in SA Health is at an all-time low. That was an observation we made in November 2016. I think if the committee was considering it again we could actually add to the list of detriments of the government's approach. Not only has it led to incredibly low morale in SA Health, I believe it has seriously damaged the capacity of SA Health as an organisation to renew.

What credibility does the government have—and I mean the government as an entity; after all, under the Westminster system one group of parliamentarians form the government in one parliament, and another group may form it in the next. But as far as the clinicians are concerned, how can they have confidence in the government being legitimate partners with them in health reform when they have this deceit year after year after year and, now we find, minister after minister? Unfortunately, we did not have the deceit buried with minister Snelling; it has been resurrected in minister Malinauskas. He dares to tell us that Transforming Health and what the government does is clinician led and evidence based.

So, we have a real problem with our workforce; we also have real problems with our infrastructure, infrastructure not in the physical sense but infrastructure in the cultural sense. We have already heard in other contexts about the clinical governance issues in SA Health in relation to chemotherapy dosing and the prostate cancer and what have you, but particularly in the area of the committee's focus, which I would call clinical service reconfiguration, the government has systematically demolished the infrastructure of the clinician voice.

Before Transforming Health started there was a body called the clinical senate, which was a senior group of health professionals who advised on clinical issues, above and beyond the political class. They were supported by a network of statewide clinical networks. What happened when Transforming Health came along? We abolished both of those, both the clinical senate and the statewide clinical networks. Instead, we appointed the Clinical Ambassador for Transforming Health, a bit like Joseph Smith and the Mormons, we appointed a series of deputy clinical ambassadors and we appointed a Ministerial Clinical Advisory Group for Transforming Health.

We did not establish statewide clinical networks. What we instead established was a series of hand-picked Transforming Health working groups. These were not selected by the clinicians. Presumably, the minister and the SA Health executive not only selected the clinical ambassador and the deputy clinical ambassadors but they also appointed all the working groups. The previous superstructure was abolished and we had the Transforming Health institution established. What we saw and what we have seen reflected in the statements I have already made was a fundamental disengagement with clinicians in the unit.

No longer was the view of front-line clinicians relevant. What mattered was where you sat in the Transforming Health superstructure. The elite spoke across all domains and the committee challenged some of those spokespeople: 'How can you speak on that area; that is not your clinical specialty,' but apparently Transforming Health, like Amway, gives you the right to speak across all clinical domains.

Culturally and structurally, there has been significant damage done to SA Health and the prospects of health reform in this state by this government, yet we have the newbie minister, minister Malinauskas, telling us yet again the same spin and the same rhetoric: health reform under this government is clinician-led and evidence-based. It is deceitful, and if it is not deceitful it is delusional. The final report of the committee, which we are specifically noting in our motion tonight, made the following finding:

Transforming Health was a health portfolio response to an increase in budget savings targets in the 2014-15 financial year.

The failure of the Government and the Transforming Health team to effectively engage the broader clinical community and the general public meant that:

the program's design did not adequately allow for local factors or reflect community values;

the health workforce and service users remained distrustful of the program; and

significant cultural damage was wrought on SA Health.

The Transforming Health process has made health reform harder to implement in South Australia.

That is the end of the finding, which was a unanimous finding of the committee. As I said, I was offended by the claims of minister Malinauskas yesterday that this government believed in clinician-led evidence-based reform. It is delusional and it is offensive.

We also saw quite a recent example of the same disrespect for clinicians in the last week or two. Let us remember that in 2015 the government decided that what was good for the western suburbs was that their emergency department be downgraded and the cardiac catheterisation laboratory at The Queen Elizabeth Hospital should be closed. Professor Horowitz, the head of the unit, was not engaged in that decision. So much for clinician-led evidence-based reform. Professor Dorothy Keefe, who was the Clinical Ambassador for Transforming Health, said that the closure of the cath lab was a no-brainer, yet two years later, ever so much closer to an election, the Labor Party thought, 'Well, we need to look at this again.'

In June 2017, Premier Weatherill announced that the government was going to retain some cardiac, respiratory and oncology services at The QEH. Minister Snelling explained it in terms of, 'Well, some clinicians say this and some clinicians say that. Sometimes we choose this clinician's advice; now we have decided to choose that clinician's advice.' In spite of the backflip, apparently, five months later there had been no action. There had been no beds returned to the cardiac unit and there was no restoration of staffing.

Then last Friday, after five months of inaction, minister Malinauskas, under cover of a university announcement, removed the after hours cardiac emergency cover. That action was explicitly contrary to the advice of Professor Horowitz. He was on the outer in 2015, he was back in in 2017, and apparently by November 2017 he is on the outer again. It was not just contrary to the advice of Professor Horowitz; it was also contrary to the advice of Dr Tom Soulsby. Last Friday morning, the head of the Emergency Department at the RAH said, 'Please don't downgrade the after hours cover for cardiac services at The QEH until you deal with a whole series of issues.' In less than 24 hours, the decision was implemented.

I put it to this house that this government has no credibility on clinician-led evidence-based reform. They are clinical advice shoppers. They will keep looking until they find clinical advice that is convenient. They will promote and prefer people until they find an ambitious mouthpiece for their policies. They suppress open discussion so the only voice they hear is the voice they want to hear. This government has no credibility on clinically informed evidence-based health policy. That is why I believe the people of South Australia, for the sake of their health, in March 2018 need to vote out this government. Whether it is minister Snelling, minister Malinauskas or the next Labor health spokesperson, I believe that they have no choice but to rid themselves of this corrupt regime.

In conclusion, I would like to acknowledge the hardworking committee in relation to Transforming Health. This report is the seventh report of the committee, that being six interim reports and the final report. It has been suggested to me that that is a record for this parliament in terms of reports from the one committee. Some people would regard such a prolific use of interim reports as not good practice, but let us discuss that when we talk about parliamentary committee reform in the years ahead.

The Hon. R.I. Lucas: Budget and Finance beat you; they do one every year for 10 years.

The Hon. S.G. WADE: The Hon. Rob Lucas suggests that Budget and Finance has done an interim report every year for 10 years. One could suggest that that is a series of clusters of interim reports in different parliaments, but let us wait until the academy hands out the Oscars in relation to the interim report tally. Anyway, what is definitely not subject to dispute is the diligence of the committee members. I would like to start with Tung Ngo, because this committee was politically challenging—sorry, the Hon. Tung Ngo. I apologise to the honourable member, the President and the council. The Hon. Tung Ngo was extremely diligent and an active participant in the committee, as were the Hon. Tammy Franks and the Hon. John Darley.

It was a pleasure to work with these colleagues because we traversed all sorts of issues and I think the committee worked extremely effectively. Of course, that is nothing to do with the Chair; that is all to do with the staff. I would particularly like to pay tribute to Guy Dickson, the secretary of the committee, and Sue Markotic, the research officer. I have only been in this parliament 11 years. Mount Gambier's TheBorder Watch was rude enough to call me a veteran MP, but one thing I have learnt is that the success of a parliamentary committee is very much dependent on the quality of the secretary and the research officer, and this committee was very fortunate to have two of the best.

I am sorry that I had to get a bit cross about the insulting remarks that the minister made in this house yesterday in terms of clinician-led evidence-based reform, but I think it is important to put on the record that this committee found that there is no such thing as clinician-led evidence-based reform under this government.

The Hon. T.A. FRANKS (20:54): I rise to briefly both note and support the final report of the Select Committee on Transforming Health as a member of the committee, and I certainly echo much of what the Hon. Stephen Wade just indicated. In particular, I would also like to thank the staff of the committee: the secretary, Guy Dickson, and the researcher, Sue Markotic. I also commend the collegiate way in which we went about working on this committee. I acknowledge the Hon. Tung Ngo and the Hon. John Darley as being very hardworking members of a smaller than usual committee.

This committee has had some seven reports, and this is the final one. When Transforming Health was announced, many in the community and certainly myself remember then minister Jack Snelling on the television set that night saying that he had not one reason for transforming health, but indeed he had 500 reasons that we needed to transform health.

Those 500 reasons, he stated, were the avoidable deaths each year that occur in South Australia. Time and time again we explored the issue of these so-called 500 avoidable deaths in South Australia that were the impetus for Transforming Health. Time and time again we received no answers as to the workings to create this figure of 500 avoidable deaths that were in any way being held to account, that were in any way being measured and that were in any way being addressed by the rollout of Transforming Health.

Time and time again we heard of the processes of the rollout of this Transforming Health and the way of the workings. Certainly, the Hon. Stephen Wade has noted that there was a clinical ambassador program, people on the payroll to spruik Transforming Health. They were partly working for SA Health, in some cases also undertaking academic roles, but certainly on the payroll to spruik Transforming Health.

Those people were involved in a series of groups. The one that I remember the most was that which decided whether or not the Repat would close. The people who were part of that committee that decided the Repat would close were quite varied. There were clinicians, there were community members and there were many bureaucrats. What there was not were minutes that were kept of any particular votes. What there was not was any sign of a democratic process being followed. We were told in the hearings that the group worked to consensus. I asked how that consensus worked, and as a Greens member of this place I will share that the Greens do work to consensus internally in our party processes and there are many models of consensus.

I was very concerned and interested to hear what consensus process this was that the group that closed the Repat worked to. The consensus appeared to be, 'It's our way or the highway' and 'You will do what you're told' and 'The bureaucrats know best.' When any dissent was shown, that dissent was not respected, that dissent was never recorded and that dissent was never reflected. There were no votes taken and there was no secretary made available to these committees to ensure administration or indeed the basics of democracy minute taking and transparent decision-making. It was a sham. It was not like any consensus process I have ever seen employed, but certainly it got the result that some wanted.

I would say this was not transforming health; this was transforming the truth. This was creating and manicuring the outcome that the minister wanted. There was never any proof of these 500 avoidable deaths that can be held accountable. There seems no care from anyone involved in the rollout of Transforming Health to now give us any evidence that these so-called 500 avoidable deaths are now being avoided. That was dismissed almost out of hand as the Transforming Health juggernaut rolled through.

I will not labour the point too much because the Hon. Stephen Wade has covered much of the work, but nearing the end of Transforming Health we were told that the clinical standards, some 227 original clinical standards, that at the beginning of Transforming Health 52 of these were not being met. We were told in the course of Transforming Health that 10 of them had been achieved. Time and time again the committee asked clinical ambassadors, bureaucrats, representatives of the government, ministers in this place, 'What are the 10 that have been met in the course of Transforming Health from its commencement until just a few months ago?'

Time and time again we did not receive answers. Lo and behold, on the very final day and the very final witness from the department to the Select Committee on Transforming Health we were given a document that proclaimed, in fact, that there were now only five clinical standards yet to be met of that 227.

Before we got our hopes up too high, just a cursory glance showed that one of those clinical standards that had now been met and supposedly achieved was that the planned co-location of the Women's Hospital with the new Royal Adelaide Hospital would address the standard with regard to the health of women in the maternity unit needing emergency procedures. The co-location of the Women's Hospital with the new RAH is not expected to be completed until 2024, yet it has been ticked off as one of the clinical standards that have now been met under Transforming Health.

As I said, Transforming Health proved time and time again to be a sham. It was transforming the truth, not transforming health, and it was getting the outcome that was designed, which was to close the Repat and to laud the new RAH. When we changed the name of the new RAH and kept it as the Royal Adelaide Hospital I think that was one of the signs, although Mike Rann, the former premier, might have liked to have called it The Marj and have had a monument to his leadership. Indeed, I think that is the legacy of his leadership—it was more about the spin and not about the substance.

Clinicians should always be involved with health decisions. They should have been involved with the building, design and construction of the new RAH. We have seen that that has been a failure, we have seen an enormous amount of money spent without listening to those who are at the coalface, those who should have been included in those decisions. We have seen this Transforming Health process—which we are now told is finished—abandoned as the shoddy piece of work it is, but no amount of spin will save the sinking fortunes of the current health bureaucracy.

Motion carried.