Bills

Health Care (Governance) Amendment Bill

Second Reading

Adjourned debate on second reading.

(Continued from 2 May 2019.)

The Hon. K.J. MAHER (Leader of the Opposition) (15:26): I rise to speak on the Health Care (Governance) Amendment Bill 2019 and indicate that I will be the lead speaker for the opposition on this bill. The Liberals promised the people of South Australia dramatic action on health, but the result of the past 14 months has been cuts, closures, privatisations, stuff-ups and more bureaucracy.

This minister, in an unprecedented way, appointed corporate liquidators to be in charge of running two of our largest hospitals. He has given them the task of cutting $420 million over the next two years, including cutting 170 hospital beds from these two hospitals. But the big winners have been the corporate liquidators themselves. KordaMentha has already cost the government in excess of $23 million and that is just until June this year, with tens of millions of dollars in taxpayers' funds in contracts likely to come.

The minister has already closed beds in our hospitals, including 25 at Hampstead, 16 at the Flinders Medical Centre and 10 at Glenside. The minister has announced a plan to sack 200 hardworking staff at SA Pathology and in 11 months is setting up to privatise the service and sell off the essential service for diagnosing South Australians to the highest bidder, all because he cannot stand up to the Treasurer and make sure that these important public services stay in public hands.

The health minister has cut a swathe through programs, closing SHINE SA clinics, closing the Centacare Cheltenham Place service and cutting all funding to the Consumer Health Alliance to represent patients. Despite these cuts to front-line health services, the priority of this minister is to invest more in bureaucrats and highly paid board members. That is his priority.

Last year, this council considered the prequel to this bill: the government's creation of 10 new boards and whole new bureaucracies and fiefdoms to run hospitals. When the budget was handed down in September, we saw how much these boards were going to cost: a massive $14.7 million over the forward estimates. To put that into perspective, that is about $4 million more than the entire non-government drug and alcohol sector receives per annum from the government—per annum from the government.

All this $14.7 million is providing South Australia is more bureaucracy and more red tape, resulting in less money to spend on doctors and nurses, and this $14.7 million is just the board fees of the new system. Board members will be paid up to $80,000 a year for their part-time roles, which adds up exceptionally quickly to a huge amount across the 10 boards the minister is creating. But we also need to factor in the cost of the creation of duplicated bureaucracies across 10 local hospital networks, the cost of extra highly paid bureaucrats across those networks and the transition costs of this shake-up are not included in this $14.7 million that is being ripped out of front-line services, including doctors and nurses.

That $14.7 million for board fees could be just the tip of the iceberg with this massive extravagant use of taxpayers' money going into bureaucracy rather than health care. Not a single dollar of this funding will be going to assist doctors, going to assist nurses, or going to assist patients in our hospitals; it will all be going to board fees and bureaucracies.

The original bill that was considered last year contained almost no detail whatsoever about how this new governance system would work in practice. Time and time again during debate and questioning on the bill, the minister categorised questions involving even a shred of detail as a 'phase 2 question'. He could not answer, he did not have a clue what the answers might be because that is to come later. The minister told us that all would be revealed in early 2019 when the phase 2 bill was introduced following very sensitive consultation with stakeholders. The government promised the chamber that well before 1 July 2019, when the governing boards were due to take effect, we would see a very detailed phase 2 bill setting out exactly how this new system was going to work.

Finally, a few weeks ago, the minister said that the long-awaited phase 2 bill would be introduced into parliament at the start of May, with less than three months and a mere three sitting weeks before the new governance system is supposed to kick in. Of course, unsurprisingly, this legislation that we now have before us represents a complete failure to deliver on the government's promise. There are no details and no costed or well-considered governance reforms. As the AMA puts in its submission, and I quote:

The AMA(SA) is yet to see the strategic intent in the measures to decentralise governance...we are concerned at the absence of any robust research, evidence or modelling with which to assess or demonstrate the likely success, yet more—albeit limited—reforms as outlined in this bill...we cannot find an explanation for what has led to these latest South Australian legislative reforms, or how they support the achievements of SA Health's own vision…we question the readiness of the 'new' to replace the 'old', what will be missed in the meantime, and who will be accountable for errors that may occur.

That is the quote from the AMA. We are told that much of what remains will be resolved in the regulations, an assurance, quite understandably, that so many of the stakeholders have been unwilling to accept from this minister who promised exactly the same thing last time: that we would see the detail this time and it is not there.

There was very little consultation with stakeholders, with the closing date for stakeholder feedback to the government being just one day prior to the bill being introduced. The government cannot expect stakeholders and the public to believe that in the course of one day the government considered the feedback from stakeholders, achieved amendments to the draft of the bill, brought the bill through their cabinet and their party room, and then introduced the bill. The minister would have us believe that all of this occurred in the space of 24 hours. It shows what absolute farcical nonsense the consultation from this minister was, and it is a far, far cry from the extensive consultation promised by the government last year and is reflected in so many stakeholder concerns.

We can have a look at what has made it into the bill. There are some very significant issues. The government is attempting to sneak in a winding back protection against board members' conflicts of interest. These boards will be in charge of the largest amounts of taxpayers' funds of any government boards in the state. The importance on the probity and the protection against conflicts of interest should be paramount.

One of these amendments would mean that board members would no longer have to report in the minutes when they have a conflict of interest. This would mean the public would have absolutely no idea what matter a particular board member considered a conflict of interest. While the government says the board conflicts would be issued in a separate register, they are not also able to be provided in the minutes at hand. It is a massive weakening of the transparency of this legislation.

The public deserves to know if a board member has a conflict with a particular contract or a particular construction project or a particular outsourcing that might occur. If the minister's proposed amendment were to proceed, then we would be entirely relying on the trust of the board member that the right actions were taken to deal with the conflict. Members of parliament are required to declare such conflicts. Members of local government are required to declare such conflicts. Why should members of the Central Adelaide Local Health Network, which will have a billion-dollar budget, not be required to declare such conflicts?

Bizarrely, this was a protection that the minister himself included when the bill was first considered by this chamber. This attempt at reduced transparency is happening at the same time as the government is trying to reduce another area of probity by broadening the category of people who can be board members. The government is also attempting to weaken the eligibility requirements of board members, removing a protection where people who have provided services to the local health network could not also be on the board. This is a potential way for a massive opening of conflicts of interest.

Under the government's proposed weakening clause, you could have a member of a private pathology company providing the newly privatised pathology services to a local health network who could also sit on the board or even be the chair of that board, and in combination with the government's other amendment it would not be minuted that there was such a conflict. It is ridiculous. You could have a consultant working for a company with a multimillion-dollar contract with that particular local health network. You could have an executive of a company that provides outsourced catering services also serving on the board. It allows for significant conflicts of interest and such situations should be very obvious.

These amendments are a blatant attempt to increase the likelihood of a conflict of interest arising, while simultaneously removing the public's ability to scrutinise such potential conflicts. This approach stands in stark contrast to the health minister's comments during debate of the first governance bill where he said:

I would urge members not to create conflicts of interest problems, probity issues, for the boards.

We are strongly opposed to these sections of the bill that will weaken probity, transparency and accountability and potentially create substantial risks for taxpayers down the track when dealing with billions of dollars that the health boards will be in charge of.

But the government is not stopping there. The minister's drive to remove accountability and transparency in regard to the health system goes on. The government is also planning on axing the Health Performance Council through this bill. This is the body that sits atop the SA Health system and, importantly, provides independence, oversight, reporting to parliament and the view of the entire healthcare system for South Australia, not just hospitals.

The minister is proposing to take away one of the only bodies dedicated to considering and providing advice on the South Australian health system from a holistic and long-term perspective. There is no replacement in this legislation the minister is proposing. While he talks about something he calls a commission for innovation he seeks to create, this will not be independent. It will not have to provide reports to parliament, it will not provide oversight of the system and it will not have an entire view of the healthcare system of South Australia.

The minister is asking parliament to take out an independent statutory body that reports to parliament and replace it with something he will set up as an office within his department with no independence and no legislative backing. As SACOSS states in its submission:

…dissolving the Council will remove a crucial piece of architecture…[and] will reduce the accountability of the health system because there will no longer be an independent body…identifying and tracking emerging issues…we do not accept that the Commission on Excellence and Innovation in Health is a replacement for the Health Performance Council as its functions, independence and authority are yet to be defined.

The Health Performance Council itself wrote to the minister warning that 'a picture of health system performance that only draws on public hospital activity is incomplete'. This would be a retrograde step by the minister and a clear attempt to remove an avenue of independent oversight and monitoring of the performance of the health system. We strongly oppose the removal of the Health Performance Council. If anything, we should be looking at ways to improve the accountability and oversight through the council, not abolishing it and replacing it with an office within the minister's department. In one way we thank the minister for bringing this to our attention because it gives us an opportunity to consider how to strengthen this.

One of the big issues that remains unaddressed since the last time we discussed the Health Care Act is what happens when there is a dispute between the local health network board and the department. The minister's second bill includes very little detail on what will happen in the event of a dispute between the chief executive of SA Health and the boards over funding priorities and service level agreements. This is an issue SACOSS raised with the government in their feedback on the bill.

Interestingly, the interim board chair of the Southern Adelaide Local Health Network, Mr Mark Butcher, appointed by the minister himself, wrote to the minister advising that there should be additional detail surrounding service level agreements to 'specify the volume, scope and standard of service provided' by SA Health to a local health network. It is telling that the government has chosen not to act on the suggestions of one of its own board chairs. The government's response to these concerns and suggestions seems to be, 'It's not going to get to that stage,' which stands in stark contrast to the minister's previous stance of legislating for the worst potential outcome when he was in opposition.

There also appears to be an unresolved contention around keeping the chief executive of SA Health as an employer of staff. This is another matter where Southern Adelaide Local Health Network board chair raised concerns with the minister, warning:

…retention of the CE SA Health as the employing authority poses a risk to an LHN's Governing Board's ability to deliver their legislated functions…[and] may present a tension for the CE SA Health.

It is also unclear who is meant to be negotiating enterprise bargaining agreements with staff. This was a question that was taken on notice during our briefings and as yet has not been answered by the government. This will need to be answered before the bill can progress.

Running in tandem with this bill is a process of radically reshaping the governance structure of Country Health SA, including the splitting of the entire country health services into six separate systems. There is a huge lack of clarity around what will happen with Country Health, including how contracts and funding arrangements will work under the new system and how much power Country Health boards will really have. As the College of Nursing has said:

…the capacity of some smaller rural Local Health Networks to function effectively may be threatened by a reduced economy of scale and a smaller skills pool.

From the proposals released so far, it looks like most of the existing staff in Country Health will simply be couched under the new label of 'rural support service'—staff who will stay in the CBD and not actually under the control of the board.

Furthermore, it is unclear what role country health advisory councils will play in the future. It appears the answer is being left in the hands of each individual country board, with no guarantees being provided by the government as to their continued operation. Again, this is another question we will have to have clarity from the minister on before we can go much further with the bill. This all feels like a recipe for conflict and confusion for our regional health systems, and it is hard to see how this can result in better patient outcomes.

In relation to stakeholder feedback, there are plenty of issues with this bill and the broader impacts of the health governance reform agenda, and many people are not happy. There is a coalition of organisations that were so dissatisfied with the lack of detail in the bill that they have written to many Legislative Councillors with suggested amendments. Those stakeholders include the South Australian Council of Social Service, the Health Consumers Alliance of SA, the Mental Health Coalition of SA, Aboriginal Health Council SA, SA Network of Drug and Alcohol Services, Australian Health Promotion Association SA, Public Health Association of Australia (SA), Lived Experience Leadership and Advocacy Network and Australian Association of Social Workers SA.

These organisations have released a joint statement raising serious concerns and recommending a range of changes the government should make to the bill. The suggestions coming out of the joint statement are all aimed at increasing performance, transparency and accountability within the proposed new governance system. The signatories to the joint statement want to keep the Health Performance Council, arguing that if the government wants to replace the council they should bring legislation to the parliament and present an alternative instead of just the abolition.

They want to give consumers an independent voice, a much-needed reform considering the government's $1.5 million cuts to the Health Consumers Alliance. They seek to amend the functions of the chief executive of the boards and put a requirement on service level agreements to include community consultation.

The signatories also want to see attempts at reducing accountability and transparency stopped. These stakeholders also want to see the statutory enshrining of the Mental Health Commission of South Australia. The government is attempting to abolish this commission after having interstate consultants write a report recommending its axing, followed by not much of a stakeholder engagement process. This, of course, was a body the minister himself pushed to create that he is now proposing to axe.

The opposition commends SACOSS and the other organisations for coming forward with these valuable suggestions. We will be considering the suggestions put forward by these organisations in detail and considering amendments that might be of assistance in making what is a bad reform a little bit better.

In conclusion, these reforms will cost many millions of dollars, add layers of bureaucracy and will achieve nothing in terms of improving patient outcomes. As some of the expert organisations have said, there is no evidence that these reforms will deliver an increase in clinical and local engagement. The entire exercise is a folly, a waste of money, with resources taken away from where they are truly needed: doctors and nurses on the ground.

While we may support amendments to make a bad bill a little bit better, the opposition will not be supporting the bill. Instead, we urge the minister to stop wasting money on bureaucracy and instead put it into where it is needed in our health system, given the inadequacies of what we have seen with the minister in this winter period.

The Hon. T.A. FRANKS (15:46): I rise on behalf of the Greens to put our position on the Health Care (Governance) Amendment Bill 2019. The bill, of course, is the second tranche, as minister Wade so often referred to it in the previous debate, of a two-stage plan to reform the Health Care Act 2008. It revises the functions of the chief executive of the Department for Health and Wellbeing and it includes provisions for service agreements between the chief executive of the Department for Health and Wellbeing and the local health networks and the SA Ambulance Service.

The bill also dissolves the Health Performance Council once the commission on excellence and innovation in health is established. It makes provision for the annual reporting and transfer of assets for the metropolitan governing councils that will be dissolved on 1 July this year. It reflects the new governance and accountability framework for the public health system or clarifies that intent and removes—or will attempt to remove, because I think that might be a little hopeful—some of the disclosure requirements that were introduced and amended in the stage 1 bill regarding conflict of interest being noted in the minutes of boards.

The Greens have consulted as widely as we have been able to in the limited time frame and note that we also were part of this morning's stakeholder briefing that was organised by SACOSS and the Health Consumers Alliance, as well as other groups including the AMA, the Australian Association of Social Workers, SANDAS, the Mental Health Coalition, the Public Health Association, the Lived Experience Network leadership group and Health Promotion. I note that the minister ensured that he had a representative at that meeting as well. It was attended by representatives of all parties represented in this chamber.

On reflection, I think that meeting is probably where I will start and express some disappointment at the lack of in-depth consultation that has occurred to get us to this stage. In terms of time frames and the correspondence that we have received, I think people who were representing various stakeholder groups did feel a time pressure. I note the correspondence from the acting chief executive of the AMA (South Australia), Dr John Woodall, to minister Wade, dated 30 April this year, noting the intention to introduce the bill to parliament on 2 May this year, only a few days later.

In that correspondence I think it would be gilding the lily a little too much to say that there is widespread dissatisfaction from the stakeholders with the general intent of the bill, but rather the processes and some of the fine details of the bill are what has caused the angst. In that correspondence from the AMA (South Australia) they have noted that they are pleased that the minister has chosen to appoint Professor Paddy Phillips, who is currently the Chief Medical Officer and (jointly) the Chief Public Health Officer, as the first commissioner to head that proposed commission on excellence and innovation in health.

I would agree with the AMA that it does sound like a very fine thing, but we certainly do not have the detail at this point of the structure, the workings, of that particular commission on excellence and innovation in health. I indicate that the Greens have listened to various stakeholders who have expressed various concerns that perhaps we are putting the cart before the horse if we are to, in this bill, abolish the Health Performance Council without seeing how what it will be replaced with is set to operate and without understanding fully whether or not the two are both complementary, which would be a useful exercise.

In that correspondence, dated 30 April, I note that the acting chief executive of the AMA (South Australia) has also noted:

We would also be concerned if the Commissioner were to report solely to the CEO of SA Health, and not have direct access to the Minister. Similarly, we would query the value of a Commission that was able to report only on the public system and not include an overview of the private system and its interactions with (and resulting impacts on) the public system.

With regard then to the dissolution of the Health Performance Council, it states:

The AMA(SA) is concerned that in abolishing the Health Performance Council the Bill will eliminate the independent and objective oversight of the system the Council has provided since 2008. The AMA(SA) has in the past supported the Council as an independent body that investigates, gathers data and provides recommendations for change. We believe it is vital for our health system that we have in this state an independent body that can investigate and assess the performance of the state's health systems—and that can do so without fear of retribution.

The Council has additionally proven its value in examining the pieces of the health system—public and private, state and national, primary and tertiary—and the issues within it. It has also performed the role of examining the impact of programs that start and stop; to measure their success; and to pinpoint reasons, such as limited access to data or the absence of measurable targets, that such measurement may not be possible. We note, for example, that in its most recent report to you [meaning the minister] tabled in parliament on 4 April 2019, the Council offered advice, including that in many cases the data it sought to monitor and evaluate services was not available—including data that reported health cut outcomes, including patient-reported outcomes that arise from services in public and private sectors, to inform clinical improvement and policymaking. This is an onerous omission in an era when data is increasingly seen as essential to developing and guiding strategy, decision-making and performance monitoring.

I note that in the briefing notes with which we have been provided it has been claimed that the Health Performance Council's remit and output is largely already duplicated elsewhere, but I am certainly not yet convinced of that and we would want to see more about the commission that is proposed before abandoning the current mechanisms without an informed debate. I note also that the AMA goes on in that correspondence, stating:

The AMA wishes to ensure that the independent, objective oversight of the system the Council has provided will continue as a mandated element of the new Commission. We agree with its advice to you that the new governance framework should clearly (describe) how the new governing boards must work to ensure their governance reflects all dimensions of quality and safety and access and equity within their local health networks and collectively across the health system for all consumers and communities.

On that, the AMA also goes on to express some concern with, I guess, not being consulted in a timely fashion. It is unfortunate when we get to a point where bills such as this come before this place with stakeholders still very keen to have their voices heard by all members of this council because they feel that they have not been listened to and that their cautions and concerns have not been addressed. In some cases they may well be incorrect in that assumption, but in some cases it appears that we are putting the cart before the horse. Until there is more detail on this commission on excellence and innovation the Greens will not be supporting the abolition of the Health Performance Council.

I note also some of the government proposals to reduce some accountability and transparency about conflict of interest where decisions are made by ensuring that there is not just the declaration of those conflicts of interest on a register but that it is recorded in the minutes where the decisions of those conflicts of interest are most relevant. We will certainly vote to support the continuation of those protections and safeguards to ensure that conflicts of interest are transparent.

I have also received correspondence, which is a copy of a letter to the Minister for Health and Wellbeing, from the aforementioned Health Performance Council's chair, Mr Steve Tully. It notes that on 6 May this year, after the bill was tabled, the council, meaning the Health Performance Council:

The council understands and supports the government's commitment to devolve accountability and responsibility for local health service delivery to the community level. This is an ambitious program of work to restructure the South Australian public health system including provisions for service agreements with local health networks and tightly focusing the role of the chief executive of the Department for Health and Wellbeing.

The council sees many opportunities, and is working to contribute to your government's efforts to provide quality care for all South Australians. In its current form, the bill focuses too narrowly on public health services and a process perspective rather than a population wide and whole of health systems perspective. This will be to the detriment of understanding all-of-SA population health outcomes. A picture of health system performance that only draws on public hospital activity is incomplete, and may be misleading. In our role under our Act, the council advises you on significant trends in the health status of South Australians and considers future priorities for the health systems in South Australia. This whole of system approach can identify movements in health outcomes, including trends that relate to particular illnesses or population groups; as well as reviewing the performance of the various health systems established within the State. For example, in the latest 4-yearly report (December 2018) patient movement between the public and private health systems remains a huge data blind spot in South Australia, and oversight is important to ensure that the SA population is adequately and safely served.

The letter goes on to put the case, I think, that is supportive of the government's intent but perhaps issuing a level of concern that we do not act in haste and repent at leisure. Again, that underscores the Greens' intention that we will not support moves to abolish the Health Performance Council until we see what is to be put in its place in greater detail, and even then reserve our rights should those two roles in fact be complementary and positive for our health outcomes rather than detrimental.

The previous speaker from the opposition outlined some of the concerns that have been raised by many in the sector. It would be safe to say that the consumer voice is one where there are grave reservations and that by devolving the system, as we have done, the consumer voice may well be lost. I understand the minister believes that it will be picked up at those local levels but the Greens do not have faith that this will happen, and we will, in this debate, seek to ensure that there is a supported and structural consumer voice in our health system that is independent and resourced, as we would expect of a 21^st century health system.

The time has long passed where consumers were treated as simply the recipients of a health service. We know that the consumer voice is vital to ensuring the best health services possible and that that voice has to be well resourced, respected, entrenched and embedded in our system.

Finally, there were grave concerns raised about the proposed abolition of the Mental Health Commission, and I echo those concerns. That is not actually embedded within this bill, but it should be part of the framework of our discussions and debates as we proceed through the committee stage of this piece of legislation.

All stakeholders at the meeting held this morning expressed their support for the continuation of the Mental Health Commission. Certainly, I would ask at this point if the minister could respond with some rationale as to why the Mental Health Commission is being disbanded and in what format that consultation process was taken. We were told at the meeting today that it was a consultant who wrote a report.

I have not seen significant dissatisfaction with the work of the commission raised in any public fora, and certainly not raised in this place. My personal experience of working with the commission has been that it has been very much a value-add to our system, and with the NDIS fast approaching—and what we know will not accommodate, particularly, mental health consumers with the new system coming in—I think it is time for more voices and those expert voices in mental health, rather than fewer.

With those few words, I indicate the Greens will be supporting the thrust of this bill. We understand that other members of the crossbench are not ready to proceed this week but will be ready in the near future. We look forward to the committee stage. We will not be supporting all of the clauses of the bill, but we certainly will not be opposing the general thrust of the devolution of the health services. That is something that was an argument of the last tranche, if you like, tranche 1. In tranche 2 I think we should focus on getting this right, and if we need tranche 3, then so be it.

Debate adjourned on motion of Hon. J.E. Hanson.