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House of Assembly - Fifty-Fourth Parliament, Second Session (54-2)
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Bills

Health Care (Governance) Amendment Bill

Second Reading

The Hon. J.A.W. GARDNER (Morialta—Minister for Education) (11:59): I move:

That this bill be now read a second time.

Today, I rise to introduce the Health Care (Governance) Amendment Bill 2020 into the House of Assembly. A similar bill was introduced in 2019 proposing amendments to support the newly decentralised public health system. Unfortunately, the amendment bill passed the Legislative Council but did not pass in this place prior to the prorogation of parliament. However, I would like to thank honourable members for their contribution to the debate in the previous session.

Some of the amendments that were passed in the Legislative Council during that debate have been included in this new bill, in particular:

a principle for the operation of the act to ensure it is inclusive of primary healthcare networks, Aboriginal and Torres Strait Islander health services and public health services provided in local government, aged care and disability;

an additional function of the Chief Executive of the Department for Health and Wellbeing to engage with consumer representatives and other interested parties in the development of healthcare policy, planning and service delivery;

that service agreements specify that each health service provider must operate programs that promote the provision of health care for Aboriginal and Torres Strait Islander people; and

that the functions of a local health network governing board include ensuring that their local health network operates programs that promote preventative and primary health care, including the preventative and primary health care of Aboriginal and Torres Strait Islander people, within local communities.

The Marshall Liberal government took to the election a commitment to decentralise the public health system by establishing governing boards to put responsibility and accountability for our local health networks at the local level and to ensure that clinicians and communities are engaged in making decisions about their local health services.

Parliament passed the first tranche of amendments to the Health Care Act 2008 in July 2018, delivering on our commitment to decentralise the public health system and enabling the establishment of local health network governing boards. The governing boards have been operating since 1 July 2019, providing governance and oversight for health service delivery within their local area. At the same time, the government also established six new local health networks in country South Australia to replace the Country Health SA Local Heath Network on 1 July 2019.

The bill supports the decentralised system and the governing boards by establishing the new governance and accountability framework for the public health system. It largely proposes the same amendments as the previous bill that was introduced into this place to:

revise the functions of the Chief Executive of the Department for Health and Wellbeing;

include provisions for service agreements between the Chief Executive of the Department for Health and Wellbeing, the local health networks and the SA Ambulance Service; and

make minor amendments to sections of the act to reflect the new governance and accountability framework for the public health system or clarify their intent.

The bill also includes some in-house amendments moved by the government in the other place relating to the promotion of a healthy workforce culture and wellbeing for staff across SA Health. These were made following discussions with Dr Chris Moy, President of the South Australian branch of the Australian Medical Association, who approached the Minister for Health and Wellbeing seeking consideration of such amendments. Dr Moy has described the provision as representing a landmark in efforts to improve the culture of workplaces and therefore the wellbeing of healthcare workers in South Australia's public health system.

The bill also includes some in-house amendments moved by the government in the other place relating to the employing authority for local health network staff. These were requested by the Australian Nursing and Midwifery Federation of South Australia and I understand are supported by key health industrial bodies.

Under the new governance arrangements, decision-making and accountability for local health service delivery are as close to local communities and clinicians as possible to improve patient safety and provide a greater focus on accountability and transparency across the public health system. Since 1 July 2019, the governing boards have been responsible for the governance and oversight of the local health networks, with their responsibilities including:

appointing their local health network's chief executive officer;

ensuring the LHN delivers safe, high-quality services;

establishing strong relationships with local communities and frontline health professionals, particularly through the development of clinical and community engagement strategies; and

overseeing the efficient, effective and sustainable operation of the local health network.

The governing boards have been getting on with the business of governing our local health networks and have achieved a lot in the short time they have been operating. Governing boards have continued with the day–to-day business of establishing their governance committees, including audit and risk, and clinical governance committees, conducting their first annual public meetings and establishing the clinical and corporate governance frameworks to support the provision of safe, quality, and continually improving patient care in their local areas.

I wish to take this opportunity to commend our health services and the governing boards on their response to the COVID-19 pandemic. The hard work, collaborative spirit and innovation that have been evident across our health system, and the support our hospitals have offered to their local communities, have been the foundation of our state's success so far. Despite the effect of the COVID-19 pandemic, the governing boards are well underway in progressing strategic planning and setting the vision and direction for the delivery of health services in their local areas.

Our local health network governing boards have developed or significantly progressed their clinical engagement and consumer and community engagement strategies, demonstrating a strong and renewed commitment to engagement at the local level. The engagement strategies will provide for strengthened and extensive clinician and community involvement in health service delivery and planning.

Local health networks continue to build connections within their communities. The governing boards of the regional local health networks have been engaging with their health advisory councils and wider community groups, Aboriginal organisations, general practitioners, local government councils and specialists.

Our governing boards are improving the efficiency with which our LHNs deliver high-quality care to our community, establishing improved governance, leadership and management protocols. We now have a system where each governing board is accountable for the delivery of local health services within its geographic area that are safe, high quality and accessible, reflective of local values, needs and priorities, and sustainable within the resources available. Each governing board is responsible for the control of the budget assigned to their local health network and will be actively engaged with its local communities and health professionals.

The bill reflects the significant shift in the way that the department and the local health networks are operating to deliver our health services. The bill reflects the changed role of the Chief Executive of the Department for Health and Wellbeing from having direct responsibility for the administration of the local health networks to a system leadership role. Notwithstanding this, the SA Ambulance Service is still accountable to the chief executive.

As the last state to return board governance for local health services, South Australia has been fortunate to be able to learn from other jurisdictions in the establishment of our new performance and accountability framework, including gaining an understanding of how devolved health systems best operate. Service agreements have been in place in South Australia for a number of years through administrative arrangements.

As required under the National Health Reform Agreement, these service agreements have been published on the department's website. The bill formalises these agreements, and their content, and the governing boards will be required to report annually against the performance measures outlined in the service agreement. This again brings South Australia in line with other jurisdictions that have health service boards.

Governing boards are instrumental in driving the service agreement process for their local health network. Concurrent with the work that has been occurring with the governance and accountability framework for the public health system, two other Marshall government commitments have been achieved, with the establishment of Wellbeing SA and the Commission on Excellence and Innovation in Health as attached offices to the Department for Health and Wellbeing as of 6 January 2020.

As attached offices to the department, rather than being part of the department, Wellbeing SA and the commission have a level of independence to set their own strategic direction, while ensuring they meet the strategic objectives of the South Australian health system. The establishment of Wellbeing SA demonstrates the government's commitment to health promotion and prevention strategies designed to keep people out of hospital.

The creation of Wellbeing SA provides an opportunity to tackle the major contributors to the burden of disease in a coordinated and integrated way through promoting wellbeing and preventing or managing risk factors in well people, early identification of people who have an illness so that it can be treated or managed better, and ensuring people who have chronic diseases have the best care closest to their home and community.

It is well documented that early intervention is likely to be more cost-effective and lead to better health outcomes. Wellbeing SA will assist in alleviating the pressure points in the health system through the implementation of the My Home Hospital program. This program will provide care for public hospital patients in their own homes who would otherwise have required admission to hospital. The state government has also established the Commission on Excellence and Innovation in Health. The commission is based on similar entities in New South Wales and Victoria, and is established to:

provide leadership and advice within SA Health and to the government on clinical excellence and innovation;

bring together expertise from public and private sector clinicians, as well as consumers, health partners and other relevant stakeholders to maximise health outcomes for patients;

be recognised as a centre for excellence and a strong partner for clinical improvement and innovation; and

support the provision of safer, more innovative and efficient health care through empowering clinicians and consumers.

Importantly, the commission now administers and supports the statewide clinical networks, which have been re-established after being abolished by the previous government. The first four statewide clinical networks are focusing on cardiology, palliative care, cancer, and urgent care.

The commission is empowering clinicians and consumers to work together to help build a continuously evolving, improving and learning health system. The commission has committed to establish a consumer partnerships program including the creation of a consumer advisory committee that engages consumers, carers and the community by involving them in the planning, design, implementation and evaluation.

The state government has also reformed and expanded the SA Mental Health Commission with an increased focus on engagement with consumers and carers. On 6 January 2020, three new mental health commissioners were appointed with increased focus on engagement with consumers and carers. The previous health promotion, preventative and administrative resources of the commission have been transferred into Wellbeing SA, which now provides secretariat support to the new mental health commissioners.

The six regional local health networks are supported by the newly established Rural Support Service under arrangements agreed by all of their governing boards. The establishment of the Rural Support Service enables highly specialised, system-wide capacities, clinical governance and access to expertise to be made available to the regional local health networks. It supports the development of country and statewide models of care to ensure equitable access to health services across country South Australia.

It also delivers specialised corporate functions that ensure all regional local health networks have equitable access to skills and expertise which may not be viable if carried out by individual entities. This critical mass ensures that regional LHNs are able to focus resources on supporting access to care for consumers.

The Rural Support Service is hosted within the Barossa Hills Fleurieu Local Health Network, but, through agreed arrangements, is accountable to a chairs committee, comprising all six regional governing board chairs, and a management oversight committee, comprising all six regional local health network chief executive officers.

Services and customer service expectations of the six regional local health networks, with respect to the Rural Support Service, are set through formalised agreements between the six regional LHNs. I can also confirm that over half of the Rural Support Service's approximately 220 staff are located in different rural and remote locations across regional South Australia.

The issues raised by this bill have been the subject of significant consultation, including through the previous bill and, as noted, the government has in this house moved amendments which passed in the other place following feedback received through consultation.

The government, our local health networks and their governing boards, SA Ambulance Service, as well as the department and new attached officers continue their ongoing discussions with our many stakeholders as part of our commitment to strengthened community, consumer and clinical engagement in the way we do business.

As noted, the health system has shown an outstanding ability to work together and responded to the unprecedented challenges that the COVID-19 pandemic has brought to our state, something all staff within our public health system and all South Australians can be proud of. While it has been possible through cooperation, policy and administrative processes to achieve a well-coordinated health system with the desired delineation of roles and responsibilities through devolved governance, further strengthening and enshrining these in legislation will ensure that there is no doubt as to accountabilities of the respective parties in the public health system.

In closing, I would like to thank those officers from the department and parliamentary counsel who have assisted with bringing this legislation before the chamber. I would like to add my own personal gratitude to the officers from the office of the Minister for Health and particularly the Department for Health for their assistance in preparing me to offer this bill to the House of Assembly on behalf of the Minister for Health in the other place. I commend the bill to the house and encourage all members to give it their support.

The Hon. D.C. VAN HOLST PELLEKAAN (Stuart—Minister for Energy and Mining) (12:14): I thank the member for Kaurna, whom I expect will be lead speaker for the opposition—

Mr Picton: Thanked in advance, that's pretty good. I haven't done anything yet.

The DEPUTY SPEAKER: All in due course, member for Kaurna.

The Hon. D.C. VAN HOLST PELLEKAAN: Thank you, member for Kaurna, whom I expect will be the lead speaker for the opposition, for allowing me to slot in just before he has his turn speaking on this very important bill.

Health is important, so health services is one of the absolute most important things. When you think about the highest priorities that government must provide for its people, you go immediately to health, to education, to roads and important infrastructure, to safety, to police emergency services, and that is certainly not the end of it. But I say without any hesitation that delivering health services is without any doubt right towards the very top of that list, perhaps at the top. So our government takes this responsibility extremely seriously. I can add to that that, as a country outback member of parliament, this is a very high priority in my electorate as well.

Country people have a much stronger connection to their local hospitals than city people do. I do not mean that with any disrespect to city people, and I am not actually talking about people's connection to their hospital's services as patients—I am talking about their connection to their hospitals and other health services as community members, and that is for a range of different reasons, including the fact that country people regularly contribute to fundraising that goes towards local health services to supplement what comes through taxpayer support, because having health services in a country or outback district is one of the key things that allows the town that has that service delivery or that health institution in it to attract other services, which is very important.

If you have a hospital, you are more likely to have a doctor; if you have a doctor and a hospital, you are more likely to have a pharmacy. If you have a hospital, a doctor and a pharmacy, you are more likely to have a physiotherapist, etc.—it goes on and on. So people are very supportive of the core institutions and the delivery of the health services in their areas because they know that the benefit to the community extends well beyond the primary purpose of the institution or the health service in terms of contributing to the district.

A short trip back in time: not very long ago, and I am thinking perhaps 11 or 12 years ago, in country areas we had what were called hospital boards. The use of the word 'board' in that context is not the same as the use of the word 'board' that we are discussing at the moment with regard to health governance boards. Hospital boards were made up of local people, some of whom were health practitioners, but broadly speaking it was a group of local community representatives and contributors.

It would be pretty normal to have a mayor, a councillor or, ideally, some younger or middle-aged people on there, men and women, people involved in sport. It was not meant to be a group that told the hospital how to operate, far from it. None of us would think that a community group is the right organisation to tell medical professionals exactly how to go about their work. But what it was very much about was making sure that local community's needs and expectations were being fed into the medical service, an understanding of those needs and expectations.

It might be that in one community having a birthing service would be incredibly important; in another community, it might not be so important. Nobody was going to tell a gynaecologist or the GP who had those qualifications how to go about delivering babies; it was more about, using this example, of whether this was absolutely vital to retain, or was there something we should attract, or is it that there is another hospital not too far away, so would it be okay if we lost this service in one hospital and wrapped it up in another hospital. It is just an example, but it could be extended to just about any type of health service.

Another reason why country people had a very strong attachment to their local health services was that, broadly speaking, their local community leaders were on the hospital board. A hospital board might represent more than one hospital, of course; it could represent a small cluster of hospitals. In my part of the world, Booleroo, Orroroo, Peterborough and Jamestown are good examples of that. That cluster of four hospitals in fairly close proximity has been represented collectively for quite a long time.

These services—and I stress that not always but usually it is a range of medical services, not just a hospital, that are typically delivered out of the same town that the hospital is in—are very important to country people and outback people. If I think about outback in my electorate, Leigh Creek comes straight of mind.

In the electorate of Stuart, the hospitals—again, I realise this bill is about health more broadly, but these are the centres of health—are in Port Augusta, Kapunda, Eudunda, Burra, Leigh Creek, Booleroo, Orroroo, Peterborough and Jamestown. Then, of course, there are a range of hospitals that are the primary place for delivering service to Stuart constituents, but these hospitals are outside Stuart.

That might be because the constituents live near the boundary—inside but near the boundary of the electorate—so their closest or most appropriate hospital is actually outside the boundary. This is not an extensive list, but Quorn, Hawker, Port Pirie, Whyalla, Angaston, Crystal Brook and others in the country area are also all extremely important health service-providing centres for the constituents I represent here in this parliament.

Then, of course, there are metropolitan hospitals as well. I am not suggesting that my constituents have the same connection to the metropolitan hospitals, but we all know that people from the country do access health services in metropolitan Adelaide as well. Having outlined that and having outlined my interest on behalf of the people I represent in parliament on this issue, let me move on from what I was describing before as the hospital boards.

The former government changed from hospital boards to health advisory councils (HACs). There were pros and cons with that. At the time, my constituents certainly told me that there were far more negatives than positives with regard to that transition. It was a transition that unfortunately diminished—not removed but diminished—the connection between communities and their local hospitals and health services. It was not because they did not care anymore but because they did not have the same opportunity to participate.

Secondly, and I think this is actually more important, they felt that the level of capacity to contribute community perspectives, needs, wants and desires to the local health service was reduced by the move from hospital boards to health advisory councils. Not all cases but in many cases this included the management of funds and a range of other things.

There were communities who had done an enormous amount of fundraising—I am talking very significant amounts of money—who had actually set that money up in trusts where it was protected for that purpose and that community, very sensibly, and that stayed like that. There were other communities who had done similarly with regard to their fundraising but not similarly with regard to protecting or essentially quarantining that money for that purpose and that community. There was an enormous amount of money that essentially went into the health system and/or the health minister at the time. So that was a step. Very deliberately, I want to be clear that it was not all bad, but there was certainly a strong belief in my constituents that it was more a backward step than a forward step.

We fast-forward to the lead-up to the 2018 election, and the then shadow minister for health, the Hon. Stephen Wade, now Minister for Health, said very clearly we were going to actually give a good chunk of the influence and the steering of decision-making back to local communities—not telling doctors and nurses and other health professionals how they do their work but giving a good chunk of authority back to local people so that their needs, wants and wishes would be front and centre again in the delivery of these health services, and what I mean by that is which services are more or less important, how the budgets are operating, where the stresses are in the hospital that could be relieved, where the opportunities in the hospital and the health services more broadly are which could be made better use of, etc.

That is where we come to with this bill. This is the second phase of the delivery of this very important health governance change. The first stage was completed on 1 July 2019 with the commencement of the Health Care (Governance) Amendment Act 2018, which established the governing boards of the local health networks. The second stage began with the introduction of the Health Care (Governance) (No. 2) Amendment Bill 2019. That bill, unfortunately, lapsed for parliamentary reasons, but we are back here discussing the same core topics.

I am strongly in favour of the direction the health minister has taken on this topic. In my part of the world we have very good people running the new local health governance boards. We have very good people on those boards as well—good chairs, good contributors—and I know that the minister has gone to great lengths to try to ensure that the people on these governance boards are as representative of the communities that they speak for as possible and also that they have a good lay understanding of medical services, I think is the best way to put it.

They are not necessarily professional health providers, but they are people with connection—not all of them but plenty of them. That is important, too, because you do have to have an understanding of the system you are seeking to influence as a board speaking on behalf of the local community. So we have good people running these boards. The health minister wanted to make sure that there were women; that there were men; that there were people with a deeper understanding of medical health services, a deeper understanding of the needs; and that there was Aboriginal participation wherever possible—ideally absolutely everywhere, but it is a fact that we have found it difficult on some of these boards to have Aboriginal members.

It is not for want of trying, and it is not for want of capacity of many Aboriginal people either. It is just that we have not always been able to line up the right people in the right places to make it happen, but certainly I know in my part of the world it has happened, which is a good thing. I think, for example, of the very highly regarded Aboriginal woman Glenise Coulthard AM. She is a very highly regarded local person in many ways who has actually worked in health in the state government for a very long time as well.

Minister Wade has tried to make sure that these boards would be as well comprised as possible so that they can represent these communities in the best way possible. He has also made sure that there is appropriate funding for these boards to operate. He has also made sure that there is a very positive connection from the board through the local health area CEO; in many cases, but not in every case, it is the person who was leading Health or Country Health SA in that region previously.

If I think about two boards—Flinders and Upper North—Craig Packard was not the CEO previously but is now. If I think about Yorke and Northern, Roger Kirchner was the CEO before and is now. So Minister Wade has made sure that we have the right people in the right places. He has done that, in fact, in consultation with the chairs of those boards. Overwhelmingly, we have extremely good health services in country and outback South Australia and metropolitan Adelaide, but it is not always perfect. There would not be a member of this house who would not any week receive a representation from a constituent who says that health service delivery for him or her or a family member or a friend was not what it should have been. I am not trying to dodge that; it does happen.

But I am happy to be on the record to say that overwhelmingly our health service in South Australia is very good. Is there room for improvement? Yes, of course there is room for improvement. Is it just right everywhere? No, it is not just right everywhere. But is it really good everywhere, particularly if you compare it to other states and, more importantly, other nations, other places around the world? We are very fortunate with regard to the health service that we receive in South Australia.

I remember quite a few times in opposition talking on this topic and saying that, while the government of the day and the opposition of the day often disagree on health service delivery, the reality is that we are talking about the difference between 'very good' and 'better than that' or 'better than that' and 'even better again'. We have every right on both sides of this chamber to try to push the bar up higher and higher every day of the week on behalf of our constituents, but we should recognise that the bar we quite rightly are trying to push up is actually already very high when compared to other jurisdictions around the nation and around the world.

Going back to health governance boards, I have recognised already in my electorate a key difference. We still have health advisory councils and they are still doing very good work. We have a collection of health advisory councils, which jointly come together under a regional health board. They work collaboratively together. I know that the regional health boards in my area are very respectful of the HACs, and in many cases people who were previously members of HACs have gone onto the health governance boards. In many cases, the people who were previously on HACs have stayed on HACs and decided, 'No, my interest isn't in the bigger region. My interest or perhaps my capacity to contribute is in the smaller part of the region, my home town or my home district.' It has worked both ways and it has worked very well.

As a country and outback MP, I will always do everything I possibly can to support people with regard to the delivery of health services. I know that my colleagues in the country and in the metropolitan area feel exactly the same way. I know that our Premier and our health minister feel exactly the same way. Whether it is the volunteer ambulance service or the most senior person in the largest hospital in the state, we want to make sure that the right people are doing the right job and delivering the right services for the communities.

Service delivery to the patient is one thing. It is a far more immediate issue. While that care might go on, in some cases for years and years, it is a far more immediate issue and a far more concentrated issue between health service professionals and patients. What this health governance system is about is making sure that there is very strong community representation on what are the right types of services to deliver in these country, outback and, yes, of course, metropolitan areas as well, although that is not the focus from my electorate's perspective.

We are determined to get this right. We are determined to get it as good as we possibly can. We recognise that the day we get it as good as we possibly can, the next day things have changed, adjusted and moved on a bit, so we need to keep evolving. As health technologies improve, as patients' needs change and as demographics change, this is something we will need to keep working on, but we will not back away from the fact that we want local people to have a strong input into local healthcare delivery.

Mr HUGHES (Giles) (12:34): I also rise to add a few words as a country member. I would point out that I am not the lead speaker. I am sure our lead speaker will speak at length and point out the deficiencies in the approach. Having said that, in principle I would be a supporter of the devolution of responsibilities, or some responsibilities, to the level that is best able to handle it.

We can have a discussion about frameworks. That is all well and good and, depending upon the effect of the framework, it can make a difference to ordinary people's lives when it comes to health and especially some of the acute issues people face. But, at the end of the day, the success or otherwise of any policy will be determined by the improvement at the grassroots, especially in this case in regard to the improvement for people in country areas.

We do know that when it comes to people in country areas, and especially the more remote areas, the health outcomes in terms of both morbidity and mortality are worse than in the metropolitan area. Sometimes we need to break those figures down, because one of the elements that is at work is that it is not just a case of access to services; there are strong socio-economic determinants when it comes to health outcomes.

You can look at the local area networks that have been developed. I look in my area, and the people on the board are good people, but when I look at some of the really big issues in my electorate in terms of morbidity and mortality, I cannot go past what is happening in the APY lands. The figures came out, once again, just the other day to demonstrate the gap when it comes to longevity. Comparing somewhere like the APY lands to some of the suburbs in Adelaide, the average life expectancy in some of the suburbs in Adelaide is close to 80-odd years, whereas in the APY lands we are talking about 52 years. There is a huge discrepancy—a huge gap—and of course changing the way that we deliver, changing the way that we come up with particular structures, is not going to address that. Yet these things, from my perspective, are amazing differences in what is an advanced country.

I take the minister's comments about the quality of health systems in this state and interstate. We have high-quality health systems and certainly, as he said, in comparison with other nations. I would say you would probably find that northern Europe and the Scandinavian countries do really well. They have systems that are as good, if not better, than our systems here in Australia, but I guess the marker of those really effective systems overseas and here is that they are essentially public systems.

We do not have privatised systems. We do not let the market rip. We know that when it comes to health, universal health systems funded by taxpayers are the way to go, and they produce better results in respect of a more equitable outcome, notwithstanding the huge gap between people who live in places like the APY lands and elsewhere in South Australia.

When I said that we can play around with frameworks, we can do this and we can do that, but at the end of the day people in country South Australia want to see the services delivered, wherever possible—and it is not always possible—in their community or close to their community. Those opposite are often quite disparaging about the role Labor played when we were in government when it came to regional South Australia, but the facts do not actually support the position they take.

The member for Flinders would have known that there was significant investment in the upgrade of facilities in Port Lincoln. There was a $70 million investment, the combination of a federal Labor government and a state Labor government, in the hospital in Whyalla. There were upgrades in the Riverland, upgrades in Mount Gambier and upgrades in other regional communities.

I know that in my community, once upon a time there were no acute psychiatric services. People had to be put in the back of a paddy wagon to be taken down to Adelaide. You can imagine what all that entailed and how distressing it was for the person, for the family and for the police, so it was great to see an acute facility and a number of beds set up in Whyalla with some decent wraparound services.

When we look back, there was no dialysis in Whyalla. There is now dialysis, and we committed to its expansion. As part of that $70 million upgrade, we saw an expansion in the delivery of cancer services in Whyalla. We saw an MRI go into Whyalla. Other regional hospitals also did benefit.

Towards the end of our session in government, we did allocate money for the upgrade of smaller country hospitals. I would be the first to say that that should have happened sooner. The budget allocation in place with the current government does not differ from the budget allocation that Labor put in place before it lost office, but it is one of those issues where I say we should have acted sooner. We are not perfect, and clearly, given what is going on at the moment, the current government is not perfect either.

We can devolve, to a degree, down to regions, but at the end of the day we do have a state system. You could probably argue that the largest country hospital is the RAH. The number of people from country South Australia who need to come to our facilities here in Adelaide is significant. Like I said, it would be great to have some additional services in the country, but there is a lot of complex stuff that requires a large hospital, where you have particularly expert teams that focus on a particular area. You cannot get that in country areas to the same degree.

We know that once upon a time we used to have more professionals living in communities in country South Australia. If anyone gets the opportunity to go and see Yer Old Faither, it is about John Croall, an obstetrician who came from Glasgow to live in Whyalla. Heather Croall, the director of the Fringe, made a documentary about her father. It is actually an interesting documentary about what it also says about the decline in the willingness of professionals to come and live in country communities.

Once upon a time, we had two obstetricians resident in Whyalla. Now we have none. I spoke to constituents a couple of years ago during the term of this government, but I am not saying it would have been any different under our rule. One young woman came to see me who said that during the course of her pregnancy she had seen seven different obstetricians. They were trying to bring in obstetricians as locums from overseas to try to have a service. My first kids were twins. In fact, it was John Croall who delivered them by caesarean. You can no longer do that in Whyalla. You would have to go to either Port Augusta or Adelaide. I am using that as an example of the changes that have occurred.

Once upon a time, professionals would be willing to come and live in regional communities, but that is less so. That is across the board now with many professional groupings. These are complex issues to address, but one of the things that is impacting upon hospitals in regional areas is the lack of GPs. That is essentially a failure of policy at a federal level. We are probably short 50 to 60 GPs in regional South Australia. When people cannot get in to see a GP, when the books are full, they end up in a hospital, and that puts more pressure on our hospital system. It means those primary health services that should be available to people in regional South Australia are more rare and people then delay getting treatment, which makes things worse.

If we are serious about equity and access for country people, if we are serious about dealing with some of these inequities, if we want people to live in regional communities, we have to address these problems. I have said it here before, I have said it elsewhere and I have said it for many years: unless there is a fundamental change in the provision of Medicare provider numbers we are always going to struggle. That is only one part of the jigsaw, but it is a significant part of the jigsaw. Unless we start to deal with that, unless Medicare provider numbers are allocated on the basis of population ratios and the medical needs that exist in communities and regions, we are always going to struggle.

As taxpayers, country people are making a contribution through the Medicare system—which is a great system—to supporting a concentration of GPs in the more salubrious suburbs in the metropolitan area. Once upon a time, GPs would be willing to come out to work in regional communities. I know there have been a whole range of changes in lifestyle expectations and other expectations, but if we are serious about treating country people in an equitable fashion these issues do need to be addressed.

Some of the smaller communities struggle to get even one GP. There is the community of Cowell, 100 kilometres south of Whyalla. There is a medical practice in Whyalla that delivers a service there. It is not a 24-hour service; it is around about three days a week. Those doctors do not get visiting rights at the Cowell hospital. What has been shared with me is four really serious examples of where a doctor in the community could not go to the hospital to treat somebody who was in a serious way. The delay in treatment could have well put the life of one of those people at risk; in fact, one person did pass away.

Instead of trying to work in a collaborative way, how can we support that practice that is delivering a service to Cowell and do it in a collaborative manner with the hub at Cleve so that the community of Cowell gets a better all-round service? If you look at the bureaucratic inertia when addressing some of these issues, sometimes it is personalities in different places that put blocks in the way. What it means is that the lives of people in country communities are put at risk. A doctor there and then in that community is not allowed to go to the hospital because they do not have visitation rights.

I am sure the member for Flinders is probably aware of some of these issues as well on Eyre Peninsula. If devolving can help resolve some of these issues, that would be a good outcome. Irrespective of the framework, sometimes you have to look at these things and common sense has to prevail. Hopefully, eventually it will when it comes to the delivery of services to some of these smaller communities.

One of the issues that comes up is PATS. We all get complaints of one sort or another when it comes to the PATS system. It generally works fine, but once again the conflict is when someone from a country area might well have had continuity of service from a specialist and that specialist might be in Adelaide. The PATS system would often deny those people payments, because they would say that while there was a visiting specialist in, say, Whyalla or Port Augusta or Port Pirie, they were closer and you had to go and see them. So the continuity of service is broken down.

The other thing about that continuity of service is that you might go and see that visiting specialist, but we have all had the experience in regional South Australia where you might have a visiting specialist who is there for a year or two and then they are gone. You cannot guarantee that ongoing service, whereas if they were seeing a specialist who might have been treating them for 15 years, who knew that patient back to front, PATS says, 'Nope, it's your choice if you want to go and see that person. You can go and see a person that we can't guarantee any continuity with closer to where you live.'

We know that continuity of service is incredibly important when it comes to better health outcomes. We know that when there is miscommunication between the different levels of the health system things have a tendency to go wrong. One person who came to see me—not the patient, but the wife—for a range of reasons ended up with a terminal condition that was misdiagnosed; there were a whole range of other things going on. Because there was not effective communication between the 'revolving door' specialist in Whyalla, this person had to go and get a specialist in Adelaide where they actually spoke to each other. That person was then denied their PATS.

I would have to say that I give a plus to the minister here; I wrote him a long letter about this and they actually changed the policy so that people with a terminal condition did not have to go through the usual rigmarole and were just automatically entitled to PATS assistance. That was a good initiative on the part of the government. As I said, the test of any policy change is what difference it will make to the lives of people in Adelaide, obviously, but to the lives of people in country South Australia, where the health outcomes are not as good. As I said, that is not just a question of access and equity; there are socio-economic determinants at play in many country communities.

The challenges we face in country communities are not just challenges for the state, but the state needs to be putting far more pressure on the federal government when it comes to the delivery of primary healthcare services through GPs. Despite the money that has been spent, and because it has not got to the core of the issue despite everything, the situation in country areas in terms of GP services appears to be getting worse. It also appears to be getting worse across a whole range of professional health services.

There are some complex challenges there. Some of it might be incentives for GPs and others, Medicare provider numbers, issues for some communities about livability and issues about the quality of educational resources. It can be a whole raft of things. As someone who has lived in a regional community for nearly all my life, I know you can have a good life in a regional community, but there has been a disconnect with our professionals today and in the last decade or two.

There has been a disconnect, and I see the disconnect not just in relation to health services. I see the disconnect when senior managers in resource processing companies who used to live in a community no longer live in the community. We see people senior in the education system who deliver services to our communities no longer living in those communities. There is a wider issue here, but there are specifics we need to address when it comes to country South Australia and health services.

Mr ELLIS (Narungga) (12:54): I rise to make a contribution on this bill and recognise the work that has been done by the government thus far to devolve decision-making into localised regions. It is a wonderful initiative, in my view, to make sure that those who have a passionate interest in local health care have the ability to influence the decisions that will impact their lives and their ability to access that health care. I think it is a tremendous initiative, and it was pleasing to be a part of the government that initiated and enacted those changes.

By way of background, health care was one of the primary reasons that I nominated for the election. For as long as I have been paying attention to politics and decision-making and local issues, health care has been one of the primary concerns of people in the Narungga electorate and they have taken a strong interest in health care and making sure that we can continue to maintain a strong level of health care in our region, and make sure that we continue to have people providing specialist services and access to an appropriate number of GPs and the like.

For as long as I have been paying attention, that has been one of the primary concerns of the voters of Goyder and now Narungga, and it was one of the primary reasons that I nominated to represent those people in this place. That particular interest peaked, in my view, as Transforming Health began to take hold. There was significant concern within our community about the effect that Transforming Health would have on local services.

I remember as clear as day that one of the pivotal moments of my time as a candidate, as a preselected candidate for the seat but not yet a member, was a town hall meeting held by the previous member, Mr Steven Griffiths, regarding the Yorketown hospital and the decision of the Transforming Health administration or the executive to start the wind-back of surgical services at the Yorketown hospital and the effect that that would have on the local community.

The Yorketown Town Hall is quite a big space but it was absolutely packed out from the ground floor through to the rafters. There were people everywhere. The view in that room in that building was unanimous at that time: they did not want to see any winding back of those surgical services at the hospital. I cannot speak for all of them, but I think the view of many was that it was the thin edge of the wedge and that starting to remove surgical services might then precipitate the removal of other GP services and health services.

Yorketown, although it is not far as the crow flies from Adelaide, is quite remote compared to—maybe not remote but it is rural and a long way to drive if an ambulance is the only way to get there. The view of the community at that time was that Transforming Health would have or could have a significant impact on their community and their local services and that it ought to be resisted at all costs.

That was one of my primary inspirations for nominating. I think that we in this place and the government have made wonderful progress in improving health services on the peninsula and in the seat of Narungga, starting at Yorketown where, as a result of that town hall meeting and the groundswell of community support that followed it, there was a commitment by the opposition then and the aspirant government to fund the upgrade of the surgical theatre at Yorketown. I can report to this house that that work has now been completed and a number of lists have been filled for colonoscopies. That is good.

That was a wonderful display of democracy working, where people decreed to the government, to the people making decisions, that they would like to see those surgery services remain, and the money has been spent to upgrade the theatre to make sure that that is a possibility and that it can happen.

There have been other important things. The Ardrossan Community Hospital is an important one. It is one of the few community hospitals around the state, as I understand, and it survives almost solely on the generosity of donors who contribute to its coffers to make sure that they have enough money to run the hospital. They had an issue where everyone who presented to the A&E had to then be transferred to a public hospital, and they had to bear the cost of that transfer which was proving to be quite difficult. I seek leave to continue my remarks.

Leave granted; debate adjourned.

Sitting suspended from 12:59 to 14:00.

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