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Legislative Council - Fifty-First Parliament, Second Session (51-2)
2008-02-14 Daily Xml
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HEALTH CARE BILL

Second Reading

Adjourned debate on second reading.

(Continued from 13 February 2008. Page 1694.)

The Hon. A.L. EVANS (15:49): This important bill fundamentally changes the way we operate our country hospitals and potentially will have a significant impact on the delivery of health services in the bush and regional areas. Family First believes every person is entitled to just and equitable access to quality health services and is committed to providing opportunities for all families, particularly our under privileged and isolated person's and aged persons and those in remote and rural centres to receive appropriate medical care. The focus of the bill, the minister said, is in response to one of the recommendations of the Generational Health Review report, which has been repeated on a number of occasions as:

Clearly identified fragmentation and duplication of planning, funding and governance arrangements as major inhibitors to the development of a coordinated health system and a systematic approach to improvements in health outcomes in South Australia.

In June 2003, following the release of the report, the government stated clearly that 'there will be no forced removal of local boards in country South Australia', and yet the government in this bill is doing exactly that, and proposes to combine a large number of hospital boards—I believe 44—into a centralised structure. The Better Choices, Better Health final report of South Australia's Generational Health Review, published in April 2003, was chaired by Mr John Menadue AO, who has been quite vocal in his opposition to regional boards. He has previously said of these boards: 'They maintain little fiefdoms, silos, they look after their own patch and resist integration'.

I will take this opportunity to disagree with Mr Menadue because, frankly, my dealings and discussions with members of the country hospital boards have left me satisfied that they are doing a wonderful job with limited funding and with sometimes mind-boggling logistics, staffing or other problems that arise from being in the country, particularly when we are talking about the far Outback. The local boards know the people, the country and the difficulties that the Outback faces, and there will clearly be something of a loss if the boards are centralised in Adelaide.

This bill has seen community consultation over about a two-year period, with a draft bill being issued on 1 August 2007 to stakeholders. The government has given some concessions. However, in essence, the bill still abolishes hospital unit boards and introduces centralised decision making. The Ambulance Services Act 1992, the Hospitals Act 1934 and the South Australian Health Commission Act 1976 are all repealed.

The ambulance services are brought under the direct responsibility of the Minister for Health rather than emergency services. There are new licence provisions for ambulances and private hospitals. A health performance council is set up to protect consumers, which also has power to set up health advisory councils across the state—which, however, will operate in a solely advisory capacity.

All the while, the primary argument for this bill has been the Generational Health Review. As the member for Bragg in the other place has pointed out, however, there are glaring omissions from the governance structure proposed in the report and the one found in this bill. The bill clearly cherry picks one facet of the report but, as the member for Bragg stated, fails at every level to implement other key recommendations—the regional structure for the country to retain a real voice in health service deliveries and, with that, the capacity to remain directly involved.

The removal of hospital boards, along with the centralisation of (on one figure) 25,000 employees of the Department of Health, fails to acknowledge the key role that these boards have had in country communities since the settlement of South Australia. Contracts for goods and services, presently supplied locally in many regional hospitals, will go to the city. Further, the bill fails to recognise the deep community bond that many country towns have with their hospitals and health services. Often the hospitals are set up at great cost and by the sweat and tears of those locals. Individual businesses and councils in the areas support their hospitals and, in centralisation of the boards, something of the local connection is lost.

In July last year, the Renmark Paringa Council and the Renmark Hotel chose to stop providing financial support to the Renmark hospital because of the uncertainty regarding this legislation. Community organisations raise money for hospital wards, beds, gardens and so on, and if management goes to Adelaide how many community groups will stop raising money, with the view that the hospital is no longer really theirs?

A further issue raised by a constituent refers to the Menadue report's reference to integrated community care centres, which will provide 'expert 24-hour, seven-day medical, nursing and allied health cover, and triage to ensure individuals can have most of their health needs met locally; and an accessible intermediate step between local communities and state-wide referral hospitals for patients who require complex diagnostic or treatment procedures'. I understand that the current plan is to locate these centres in Port Lincoln, Whyalla, Berri and Mount Gambier. Places such as Roxby Downs, Kangaroo Island and the Far North are excluded. The concern is that these hospitals will now officially be recognised as only an intermediate step between local and major state hospitals.

The statewide referral hospitals will increasingly be the only ones capable of dealing with certain cases. I understand already that, due to a backlog in obtaining Flying Doctor services, rural patients are being flown to hospitals such as the Royal Adelaide Hospital for treatment but are unable to obtain a flight home. As a result, many beds are taken up by patients from the Outback who should otherwise be discharged. Increasing centralisation will only increase this problem, unless sufficient funding is granted to the Flying Doctor.

The Balaklava and Riverton District Health Service is among the most vocal critics of the bill before us today. I also have letters from Booleroo Centre imploring Family First to oppose the legislation. This is a government that believes in centralisation and, in essence, big government. The Minister for Transport in a 13 November press release noted the government's 'opposition to privatisation by bringing asset ownership back to government.'

We have seen, very recently, the centralised bureaucratising of the SSABSA board and control taken of our rail networks, along with the formation of the Marxist-sounding Rail Projects Directorate. This sort of health care legislation is not new, either. Previous Labor governments have also sought to centralise health care, most notably after the Bright report in the 1970s. Of course, on the other hand, the government has a mandate to do such things and Family First will support measures that are honestly designed to reduce waste.

It is fair to say that Family First does have a number of serious concerns about this bill. We are not completely closed to it, however, if the government can show clearly during committee that this bill is in the best interests of the rural sector. In saying that, Family First will support the second reading of the bill and will listen closely to arguments during the committee stage.

The Hon. D.W. RIDGWAY (Leader of the Opposition) (15:58): I rise to make a few brief comments about the Health Care Bill, and I do not want to repeat a lot of what the Hon. Michelle Lensink said in the major contribution on this bill on behalf of the opposition. My colleague the Hon. Caroline Schaefer made some comments last night from a similar perspective. Prior to coming here I was a member of the local hospital board in Bordertown. If you turn back the clock and look at the history of country hospitals and their boards, as the Hon. Caroline Schaefer said last night, they are probably the one last bit of fabric of the country community that is left.

Country towns got together to build sporting facilities, schools and hospitals and, in particular, the hospitals are an ongoing important part of our communities today. In fact, the Bordertown hospital was first built just after World War I as the Tatiara Soldiers' Memorial Hospital, and people went out and raised money and worked tirelessly to raise the funds to build that facility. Then there was a new hospital built in the 1960s, again almost entirely funded out of the community's fundraising.

I had some guests in for lunch today who watched the last bit of question time. I am glad that they are not here because I am going to estimate that they are approaching about 70 years of age, probably 60 to 65. Their fathers and mothers actually helped raise money for the facilities in Bordertown.

So, you can see that this is a contribution from a community to provide these sorts of facilities and have some input with their own local hospital board. In fact, the father of the gentleman who was here was on the hospital board, my father was on the hospital board, and they were all people from the little community of Wolseley, which is not in Bordertown but is part of the Tatiara community. That is what held those communities together. The boards were often made up of representatives from community groups in outlying regions and, in this particular case, the Tatiara region. That is an example of how many of these country hospital boards and country hospital facilities were provided by the community and then supported and had a great interest in binding the community together.

I will take a step back. The Bordertown Football Club and the Mundulla Football Club would almost fight to the death on the football oval.

The Hon. J.S.L. Dawkins: What's this 'almost'?

The Hon. D.W. RIDGWAY: Yes; it is a very passionate match when those two teams play. They have an intense sporting hatred of each other, shall we say, and yet, today, a former life member and club president of Mundulla Football Club is the chairman of the Bordertown Hospital Board, and the vice-chairman of the board is a former club president and life member of the Bordertown Football Club, but they work together in the interests of the community. That is one of the great opportunities for the community to work together.

A lot of towns are very parochial and they do like to have the best sporting facilities and cultural facilities, but the communities all realise you can only have one hospital, and it brings them all together. I think that is one of the key failings with this piece of legislation. Of course, when you remove a hospital board people start to lose interest, because they lose ownership. Of course, you have to also remember that this hospital, which was built on crown land in a country town by local community fundraising, is actually an asset that belongs to the community. Again, that is why we have a community board to administer it.

When it loses a board the community loses interest and you have, if you like, a waning of support. If you back that up with a government that chooses to centralise facilities and services, then you have country hospitals losing services. As the Hon. Caroline Schaefer commented last night, if you lose a service then you find that GPs are reluctant to go to country towns. Along with being GPs they also like to provide some extra service and extra specialist services. Some of them are anaesthetists and like to keep their registration going and keep their hand in. Unfortunately, most of the hospitals now, with this centralised approach, do not provide that service.

I know that Mount Gambier is looked upon as one of the main key regional areas. Tatiara Hospital is part of the South-East region and, when regionalisation took place, Mount Gambier became the regional centre, as I am sure you would know, Mr President. Of course, Bordertown, Keith and Tintinara are three towns on the cusp, if you like, of whether it is shorter to go to Mount Gambier or go to Adelaide. Eventually, of course, when you have an area with its major regional centre at one end, you then have leakage from the top end of that region into Adelaide or other areas. The service becomes less viable, because the South-East region services about 62,000 or 64,000 people, plus a group of people over the border who come into the Mount Gambier Hospital catchment area. As there is leakage out of that area it finds that it is unable to provide the services, even in Mount Gambier, because the people it is wanting to service are not there.

I am reminded of an event that occurred when I was on the hospital board. An ophthalmologist wanted to put equipment into the Bordertown Hospital at no cost to the South-East region in order to perform eye surgery on cataracts, etc. for some of the elderly people in Bordertown. However, the South-East region would not support that and would not allow us to do it, because it had two ophthalmologists in Mount Gambier and would not support a third one in Bordertown, notwithstanding the fact that most of the oldies in Bordertown needing that surgery would rather go to Adelaide than Mount Gambier. In the end, the ophthalmologist got a spot in the Nhill Hospital, just across the border, set up his equipment and then all the patients from the Bordertown area went across to Victoria to have their surgery done.

It just shows that these regional centres need to be better located. I understand that Mount Gambier is the biggest town in the South-East, and I hope that over the next 100 years it grows to become a much bigger city. However, I am sure that, by having the regional centre at one end of the South-East, we will see more and more leakage, and that that will back up the government's plan to have a more centralised service because more and more people will see that it is easier to come to Adelaide rather than going to Mount Gambier.

In relation to towns such as Bordertown and any of the towns along the highway, there is also a great risk for the community when you have a more centralised service and fewer skilled practitioners visiting those country hospitals and fewer quality staff because, of course, all the midwives and highly trained nursing staff we had in country towns have largely not been replaced. A lot of those people have retired or moved on, especially in places such as Bordertown, Keith, Tintinara and towns right along the main highway.

Some 2,500 vehicles travel along that highway every day, and many of them are large, heavy trucks and interstate buses. There is an interstate passenger railway line, and an interstate airline route traverses that highway. We all hope it never happens, but, unfortunately, I am sure at some point there will be a tragic major road accident that could involve trains, buses, cars and road transport. There is also an outside chance—and I accept that it is a very outside chance—that there could be an accident involving an aircraft. If you do not have a vibrant hospital that is well staffed and well resourced, you simply will not have the people on the ground to provide all the first aid and road trauma support needed.

I keep referring to Bordertown because I have had such a long association with that town, but the Keith hospital is about as far from Adelaide as a helicopter flight, so retrieval is quite quick. However, Bordertown goes beyond that, so it is just that bit more difficult. I think there is a really strong case that we should be maintaining the hospital boards within the communities—they are the fabric of the communities—to provide a service that is perhaps not for the local community entirely but on some of those major transport routes there is a sort of response service that will ensure that, if we do have a major road accident, we have the personnel on the ground to support those people who are injured.

I will close by saying that I have received a letter—and we all receive a number of letters—from the District Council of Grant (the Hon. Rory McEwen is a past mayor) which states that the council has noted the Health Care Bill and the government's proposed model, particularly as it relates to existing hospitals. The letter goes on:

The council considers that there are a number of significant deficiencies in the model proposed which will not lead to better health service delivery and, indeed, disempower local communities.

I am sure the District Council of Grant will be sorely disappointed that this bill and its representative in the cabinet, someone the Premier talks about as having a country influence and being, along with the Hon. Karlene Maywald, the government's country conscience (that is, the Hon. Rory McEwen) has allowed this bill to progress to where it will tear the heart out of health services in rural South Australia.

The Hon. J.S.L. DAWKINS (16:09): I note the contribution of our lead speaker, the Hon. Michelle Lensink, as well as the contributions of the Hon. Caroline Schaefer and the Hon. David Ridgway, my leader in this place. I think the background of my two country colleagues in particular has brought something to the debate because I think that when you do grow up in a local country community that relies on the local health services you do have that background that perhaps others do not.

I am opposed to this bill. It is a bill that takes us back to some previous moves to centralise health services. In my view, to replace local hospital boards with health advisory councils is a bad move, and I am opposed to it. I also wish to bring some personal experiences to this place today: one very close to home and one that I have had experience with as a member of parliament but also as someone who has visited the Riverland frequently all my life.

I will initially talk about the community of Loxton and the Loxton Health Service. I will never forget the amount of work done in the Loxton community in the past decade or so to raise money from that community for the local facility. There was such a wonderful community spirit involved in that campaign, and The Loxton News had a barometer on the front page showing the amount of money being raised for that project—many hundreds of thousands of dollars from the Loxton community. It was a project which community members were all very proud of and which was led by a very strong local board.

The board drove that, and it went out into the community and sought other champions for this local campaign. It did not mean it did not want money from the government for the project, but it showed that it was prepared to put its hand in its pocket and say, 'We want these facilities in Loxton and we are prepared to go out and put our hand out there and deliver some of the money.' As I said before, I have no doubt that that would not have happened without the strength of that local board providing leadership in that area.

The Hon. Mr Ridgway talked about the differences between the Bordertown and Mundulla football clubs and about how those people came together to support the hospital in Bordertown. Well, I can report that the Loxton and Loxton North football clubs are not always that close to each other in friendship—there is an enormous rivalry there, as you would understand, sir, with country football—but people from both entities came together to support the campaign to raise that enormous amount of money for the Loxton hospital. As I say, it was under the leadership of that local board.

I now come a bit closer to home. I live in Gawler, and in recent years Gawler changed from the very old Hutchinson hospital (where I was born) to a very modern facility. While that facility has been established and added to by various state governments, the reality is that in recent years the board of that health service decided that it also needed to supplement the funding of the building, in particular, as well as related services, with local funding. So, the board recommended and supported the establishment of the Gawler Health Foundation. That was established some three or four years ago—in fact, my wife Helena was the first chair of that foundation. She is no longer in that position, but all those who have been on that foundation and who have chaired it have been passionate about raising money for the local community's health service.

They have done that in a number of ways. A couple of reviews have been put on where the health fraternity have had a bit of a shot at themselves, with great humour, and raised a lot of money—and I have been privileged to be the MC on both those occasions. In another example, the Gawler Health Foundation is about to conduct a farewell to McLeod's Daughters as a fundraiser, and I am sure thousands of people will attend that function. In fact, some have already booked to come from New Zealand, because they are such avid watchers of the show. That just shows the way in which locally-based committees and boards can get out there and raise money for these facilities.

That health foundation will continue, but my concern is that it was established with the strong support of a board. It will now no longer have the support of a board and could, at some stage, and at the whim of a centrally-based executive, be gutted. That would be a great shame.

I will not delay the council much longer, but I think another aspect we need to look at in relation to the value of health boards in this state is the number of people, the number of leaders in our community, who have developed their leaderships skills working on (and in many cases, chairing) hospital boards—and we have heard it from members of parliament here and in the other place. Along with other local bodies, these organisations are a valuable tool in the development of leaders across this state.

I believe that if you take away those boards, and you take away the responsibility that goes with running those boards, then you lose that aspect. I was told by a colleague on the other side of the fence in another place that these people still get that experience on a health advisory council, but it will not be the same, because they will not have that ultimate responsibility for making sure that that local facility runs well and efficiently for the local community.

Those are just a couple of examples of the reason I think this is bad legislation, and I intend to oppose it.

The Hon. R.P. WORTLEY (16:17): I stand here today to speak in support of the bill, which proposes, through necessary reforms, to bring the health care system in our state well into the 21st century. As citizens of South Australia we are indeed fortunate to have access to reliable, effective and safe health services.

Our doctors, nurses and associated health care practitioners are well trained, committed and professional, as are our administrative and support staff. The work of our volunteers, who so effectively underpin the provision of high standard health services, is ably and generously supported by the communities in metropolitan, rural and regional areas.

It is undeniable that the health expectations and the health needs of the community are now considerably different from those that gave rise to the South Australian Health Commission Act in 1976. We are far from alone, in national and international terms, in anticipating an ageing population and increasing incidence of chronic disease, advances in medical-related technology and the need for improved infrastructure and quality assurance, in both staff and service.

The bill sets out a governance model which not only meets the needs and expectations of the committee in 2000 but in fact provides a foundation for achieving equitable coordinated health care in our state for many years to come. As my colleague the Minister for Health in another place mentioned in his second reading contribution last September, the Generational Health Review report of 2003 identified fragmentation and duplication of planning, funding and governance arrangements as major inhibitors to the development of a coordinated health system and systemic approach to improvements in health outcomes for South Australians.

Reforms proposed in the bill streamline governance arrangements and remove unnecessary bureaucracy, resulting in a more efficient, cost-effective and equitable system. Today, I want to focus my remarks in relation to this bill on an area of particular interest to me, namely, the wellbeing of South Australians in rural and regional areas. Health services in these areas will benefit enormously from the proposed simplification of governance systems. Presently, there are 45 separate incorporated health units in country South Australia. Each of these is managed by a local board and each employs staff, manages finances and maintains clinical standards.

These volunteer boards, which have for so many years demonstrated a balance between country communities and local health services, are now subject to increasingly complicated legislative, industrial relations and contractual requirements, among many other complex matters.

The unified system outlined in the bill will ensure consistency in policies, standards and expectations across all our health services. Indeed, the bill is the basis for an innovative mechanism of governance by which corporate responsibilities, management of finances and of risk, including medico-legal risk, and staff recruitment will come entirely within the ambit of Country Health SA.

The best standards of care will be ensured by across-the-board mandated quality and safety protocols. While the vast majority of these boards have done an excellent job, a board in the Riverland comes to mind. A while ago, a doctor, who had a particular disease and drug problem, was injecting patients with the knowledge of the board, and it caused some very big problems in the community. While the vast majority of boards do a great job, there are instances where those standards have fallen down.

Country Health SA will recruit and select staff through a centralised workplace planning process. As an added benefit, it is anticipated that coordinating staff through a linked network of hospitals will provide increased sector-wide career opportunities for staff and promote the retention of a skilled and experienced workforce.

Health advisory councils are to be established, and these will replace the voluntary boards. So, the link between the community and the hospital will be maintained, and I think that we all agree that that link is very important. The health advisory councils will be made up of local representatives who will advise and advocate on behalf of their communities.

Health advisory councils will continue to be involved in senior staff recruitment, and incorporated health advisory councils will hold assets, administer gifts and trusts, and raise funds, should they so choose. I understand that the majority of country boards support the establishment of these councils, which is quite in contrast to the scaremongering of the opposition in regard to this issue.

In a hugely significant week, when both federal and state governments have offered apologies to the Stolen Generations, it is important to note that the principles of this bill acknowledge the health needs of Aboriginal people and the importance of supporting indigenous culture and recognising indigenous values. Its principles will realign the health system to work more appropriately towards providing services to Aboriginal communities in metropolitan areas and in regional, rural and remote areas.

With regard to aged care service provision, which is particularly significant in a number of country communities, it should be stressed that the bill does not impact on accommodation bonds. The retention amounts will continue to apply to the benefit of the facility where the service is provided. Principles for the operation of aged care places under the bill have been settled and tabled in the other place by the Minister for Health.

There are challenges ahead for our health system. The Health Care Bill enables us to meet those challenges in a planned and structured fashion so that better health outcomes can be ensured in rural and remote areas, as well as in the major centres.

The Hon. SANDRA KANCK (16:23): I want to begin with a little bit of history because, although at the present time I am responsible for all portfolios for the Democrats, in the past I was not. At times when we had two or three MPs, I always had responsibility for the health portfolio, so I have seen quite a few changes in the past 14 years.

Back in 1994, the health minister at that time (Hon. Michael Armitage) set in place the structures for a policy known as 'regionalisation'. In addition to the local health boards, a second tier of bureaucracy was established in the form of seven regional health boards, with the local boards having to go through the regional boards for spending approval.

When the Hon. Dean Brown took over he established the new super bureaucracy, the department of human services, which established new lines of bureaucratic reporting. Local boards had to take money out of their budgets to fund the regional boards, thus reducing money available for them to produce health outcomes. The regional boards were administrative bodies only, and the money gravitating to them produced no health outcomes at all.

In a media release I put out in May 2001, I stated that I had been given an estimate from someone in the department that it was costing $5 million to fund those seven regional health services. In the decade following the introduction of these reforms, as I travelled around the state and talked to chairs of hospital boards, a lot of anger was expressed about the money and autonomy being taken away from local hospitals and given over to these regional health services. The CEOs of health services had to report via the regional health services and could not contact Adelaide directly. They never knew whether their communications were being passed on and often believed they were not. This process left providers of the services isolated and created unnecessary delays and confusion in decision making.

There were a few exceptions. Some health administrators in the Murray Mallee and Yorke Peninsula regions thought it was good to have the regional health service available effectively to act as a broker on their behalf in dealing with the Adelaide-based bureaucracy. I came to a position therefore of supporting perhaps two regional health boards, an east and west, but my preference was in fact for one. When the Hon. Lea Stevens as health minister at the time commissioned the Generational Health Review I was disappointed that one of the outcomes was that it proposed reducing the number of regional health boards by one, from seven to six. I put out a release at that time calling for the amalgamation of the seven regional health boards into one regional health board, while keeping the local hospital boards intact.

In 2004 minister Stevens reduced the number of boards for the metropolitan hospitals to three. Since then, under the Hon. John Hill, we have come down to one Country SA board, and it did not require any legislation for him to do that. When the current minister did this I publicly congratulated him on the initiative. If it was costing $5 million in 2001 to fund the boards I can confidently assert, given the rate at which those boards grew, that amalgamating them to one probably saved our health system at least $7 million per annum, if not more. That meant that that money could have been directed back into health outcomes.

In the two years since that took place, I have had no complaints—zero, zilch, nothing! Previously there were leaks all the time coming from doctors, nurses, CEOs and chairs and members of boards but now, nothing. That leads me to conclude that the current system is working administratively, as there are no complaints.

The Hon. C.V. Schaefer: There is no-one left to complain.

The Hon. SANDRA KANCK: That is true: many people who put up a fight were exhausted and have left the system. Nevertheless, it was a surprise that the proposition of this bill is that local hospital boards be removed completely and replaced with advisory councils, if they are indeed so replaced. The powers of these councils are severely limited compared with the current boards. The bill also removes the boards of the metropolitan health services, and it is not clear from the minister's explanation why we have the changes before us if the system is now working. The question to be resolved by us in parliament is whether or not this is justified, and I quote from the minister's explanation as follows:

Without these reforms South Australia risks having a public health system that is incapable of meeting the challenges identified in the GHR report and by other national and international bodies to provide a more sustainable public health system, with better and more equitable health outcomes for its population.

It is a sweeping claim, but the basis of it is not elaborated on in his explanation. It seems that the pendulum has swung back completely in the opposite direction. We had the bureaucratic madness with the seven regional health boards on top of the local health boards, and now we are going to none.

Health Reform South Australia sent all Legislative Councillors a circular in November, shortly after this bill arrived in this place. It asked four questions, which I looked at at the time and thought that, as I was preparing for this bill, I would answer those questions, which asked:

1. Does the legislation provide the structures for meaningful representation and involvement by the broader community in planning and delivery of health services, particularly at the health advisory council level?

2. Most decisions in the health system will rest with the minister and the CE of the Department of Health under the proposed bill. Whilst such centralised decision making can contribute to uniform and consistent standards, minimised inequalities and increased coherence and coordination, the decentralisation of decision making on the other hand can help enhance local autonomy and empowerment, encourage customisation and innovation and increase participation. Do you believe the bill contains the right mix of centralised and decentralised decision making powers?

3. Given that the legislation proposes that members of the independent Health Performance Council (HPC) be appointed on recommendation of the minister, are you satisfied that there are sufficient provisions in the legislation to protect the independence of members of the HPC and therefore the integrity of the health system?

4. Are you satisfied that the reporting requirements of the HPC are sufficient to discharge its duty as an independent monitor of the performance of South Australia's health system?

In retrospect, now that I have prepared my speech and looked at all the submissions and at some of the history, I regard those questions as merely rhetorical. (No doubt there is an emotional attachment to country hospitals having their own boards, and we have to consider whether the local people want control or want a say.)

John Menadue, the chair of the Generational Health Review, told a meeting at Adelaide Town Hall a month before his report was released, 'We have to be careful not to confuse community participation and corporate governance.' He also made the point that the profile of boards does not reflect the community: 'Women, families, children, the aged, indigenous Australians and people of low socioeconomic background are seriously under-represented.' That is something that could be fixed up without abolishing the boards.

In the foreword of the final Generational Health Review report, John Menadue said:

Change can only be achieved if there is a broad constituency of support. That constituency carries with it a moral authority. This report offers not only the potential for a long-term sustainable health service but also, perhaps even more importantly, it can enhance public confidence in open and inclusive public processes.

My sense is that John Menadue was highly supportive of community involvement and ownership, and I am not convinced that there is a broad constituency of support for some of the changes in this bill, nor am I convinced that what is offered is an open and inclusive public process.

The GHR recommendations included, as one of five pillars, the need to have more involvement of community, including consumers and clinicians, in the governance (and I underline that word, 'governance'), planning and decision making of health services. The Health Care Bill appears to be ignoring these. The involvement that is offered in this bill is, therefore, tokenistic. Instead, the bill offers a structure where the minister and chief executive have centralised control over all aspects of public health in the state. As far as community participation is concerned, the closest to participation is '6(h) ...promote and encourage the participation on the provision of health services'.

The bill's establishment of a central health performance council with up to 15 appointments by the Governor (read minister) will be the only body to be consulted by the minister. The bill also proposes the establishment of health advisory councils (HACs), with the minister having enormous powers, including whether they are even established; decisions whether to amalgamate or dissolve them; determining their functions, which may (or perhaps may not) include community participation, providing advice, fundraising or providing assistance with fundraising; deciding whether they will become incorporated bodies; and determining and varying constitutions.

The bill also provides that HACs, in performing their function, must (and I stress the word 'must') take into account strategic objectives. And who sets those strategic objectives? The minister—the government. The HACs will not be involved in financial or staffing issues or the setting of priorities.

The Hon. C.V. Schaefer: I doubt they will be lining up to do it.

The Hon. SANDRA KANCK: Another good interjection! Yes, I doubt that there will be people lining up for the job. The minister will have the power to appoint up to three members of each HAC. However, the bill does not provide for a minimum membership of HACs. So, if there is a HAC with three members and the minister provides three of them, it will be totally ministerially dictated. It could well be that the HACs are made up of ministerial appointments. I am not saying that they will be, but it could be that they are entirely made up of them, or they could make up the majority of the members.

This is not, I believe, the participatory process envisaged by Menadue, and it creates a health minister-centric health system. As the minister has such absolute power over HACs, they will be in no position to advocate for the needs of their community. Minister Hill, in a press release dated 3 July 2007, in regard to the HACs, stated:

They will perform a range of advisory, advocacy and fundraising functions related to their local communities. This will include providing advice on local health and service issues, planning and resource allocation to the ministers, the Chief Executive, Department of Health and Country Health SA.

I have to advise the minister that this bill does not provide for this communication stream—and, anyway, given that the very existence of the HACs will depend on the minister, the chance of their giving any frank and honest advice is extremely unlikely. The minister will not have to consult with the HACs: they are merely the avenue for broader community involvement.

It is interesting to consider comments in an Advertiser article of 14 July 2006 by Ian Yates of COTA. He pointed out that the Generational Health Review gave priority to the need for greater community involvement in the health system. He said:

The health department itself is not a fan. The culture of the department is largely closed to external influence—most health bureaucrats think they see all, hear all and know all. The Health Department would love to administer the health system without 'interference' from people who represent the actual users of the system.

Remember, that was 14 July 2006, and we did not know what was being proposed then—that, in fact, that was exactly the proposition that was coming up. Ironically, Ian Yates then went on to say, 'The Rann government is to be applauded for backing community engagement in the health system.'

The Hon. C.V. Schaefer interjecting:

The Hon. SANDRA KANCK: He did not know. Comments like those made by Mr Yates leave me feeling uneasy about this bill. Over 14 years I have been provided with information of many instances where Health Commission bureaucrats have bullied the health boards, especially in the regions. So, an important question for me in resolving the issue of dissolution of local boards is the effectiveness of these boards in standing up to the city bureaucrats. I would say that, generally, they have not been effective.

There were different incidents around the state where, for instance, regional health boards were, quite frankly, interfering in the day-to-day running of hospital decision making, and the local health boards were not able to withstand this. The Mount Gambier District Health Service was the exception: it did stand up to them, but it caused great upset and division in the community, and a lot of good people went missing in action from both the board and the hospital, having been very badly burnt in the process. And, in the end, nothing was achieved.

In considering the effectiveness of boards, I will concentrate on one of the failures. In 2002, the Port Lincoln Health Service Board failed to stand up to head office and its bureaucratic interference. Following a review in 2000, the roles of the CEO of the hospital and the regional health service were separated. Then a post-implementation review was ordered by one of the most hated bureaucrats in the Department of Human Services, Roxanne Ramsey, despite a request by the board for more time to implement the review's recommendations.

The recommendations of the post-implementation review were then foisted onto the Port Lincoln Health Service Board. The new CEO, having inherited an operating debt from the previous management, was told that the Port Lincoln Health Service had to find budgetary savings. The CEO did this by partly reducing some services across the board, which resulted in community rumblings. However—and this is really important—the Eyre Regional Health Service signed off on them and advised head office that these cuts were justified.

Despite this, with only a day's notice to the board and without any other advice from either the department of human services or the Eyre Regional Health Service that there were departmental concerns, a DHS bureaucrat flew into Port Lincoln and told the board that she wanted the CEO sacked. The board complied and required the CEO to step down immediately based 'on the advice of DHS that they have lost confidence in the ability of the CEO'. The board's own views and experiences were set aside and it did not even bring the CEO in to let him argue his case. So, what was the point of having a board at all if, in a crisis, it simply rolled over and did what the department dictated?

The current minister argued in an 891 interview on 19 June last year that South Australia has had a problem in the way health has been run. He said:

It's been run by a whole series of boards. The boards' chairmen aren't in parliament to answer the questions. So when Vickie Chapman or the opposition ask me a question about what's going on at the Royal Adelaide Hospital or the QEH, I can't say that's the responsibility of the board from the central northern area. I'm the one who has to answer the questions...I want to have a mechanism in place so I can plan and run the system. The idea of having that outsourced to a series of boards to make decisions I think is contrary to proper ministerial responsibility.

Strangely, the South Australian Health Commission Act, which will be repealed if we pass this bill, was established deliberately to create a distance between the minister and the health providers and, ironically, this was done by a Labor government.

I am not convinced by minister Hill's argument. Early on in the Rann government, legislation was passed to abolish the Passenger Transport Board on the basis of similar arguments and, sure, Patrick Conlon now runs the public transport system without a board to give him an independent view but, if anything, the public transport system has become worse without that independence built into it.

I note that Queensland and New South Wales have got rid of boards, although Victoria has not, and I ask the minister whether Queensland and New South Wales now have a better health system with better health outcomes as a consequence. Certainly, negative stories about the Queensland health system regularly pop up in our media here. I have concerns about all this power residing with the minister and his chief executive, and I wonder whether we need a body to act as a buffer between the many health services and the minister. That is the major issue with which I am wrestling.

The opposition has indicated total rejection of the bill because of the centralisation of power, yet during the eight years of the Liberal government we saw similar proposals and actions. In April 1995 a bill introduced by the Liberals, with Michael Armitage as the health minister, gave far too much power to the minister. There was a stand-off between the government and the Labor Party and the Democrats. We had a deadlock conference and the bill was laid aside. Back then it was the Liberals who wanted to abolish the Health Commission; now they are opposing it. Strangely, that bill gave the power for the minister to dissolve hospital boards, and now the Liberals are apparently fighting to keep the boards.

When Dean Brown was minister, the ALP in opposition supported the South Australian Health Commission (Direction of Hospitals and Health Centres) Amendment Bill 1999. Having opposed a similar bill in 1995, the ALP buckled to give the health minister extra powers which allowed him or her to close hospital beds, wards and even departments without having to consult the hospital board. In that debate the Labor opposition argued that the minister needed these powers and that by giving them to him or her the minister would be more able to be held accountable for the decisions. Well, that got through and I am not sure that it made any difference to accountability.

Strangely, only a few months before that bill was introduced, the then Labor shadow minister for health Lea Stevens in her 'Health Directions' paper had this to say:

The public also feels disempowered by a top-down approach that is neither open nor accountable. South Australians do not want to be told what's good for them by those who are tearing the system down.

That is the Labor shadow minister who said this back in 2004-05. The Hospitals and Health Services Association of South Australia wrote to all MPs at that time raising their concerns about the 1999 bill, particularly relating the views of country hospitals, as follows:

Many members—

he is talking about the chairs and boards of country hospitals—

question the future role of community boards once a minister has the power to direct a health service. In fact, some question the need for boards should the bill be passed.

In April 2000, when we debated that bill in this chamber, there was no outcry from Liberal Party backbenchers at the power this was giving to the minister, and yet now the Liberals are berating the government.

The Hon. T.J. Stephens interjecting:

The Hon. SANDRA KANCK: A new broom? Well, that is very refreshing to hear. We have seen the impact of that with reductions and closures of a variety of different services in our hospitals, the most recent such decision being that of closing down the birthing services at Modbury Hospital. I have to say that it is hard to reconcile the changing positions of both the Labor and Liberal parties over the years, both in government and in opposition. Part of the task I have is actually to work out what the political agendas are for both parties in this to allow me to make my own decision.

I note also that consumers have been left out of the bill. Currently, most public hospitals in South Australia have consumer advisory councils, which provide advice to hospital managers from a consumer perspective about key aspects of the operation of the hospital, as well as to develop appropriate mechanisms for consumer involvement in the activities of the hospitals. Consumer advisory councils have no place in this bill; instead, they will be replaced by HACs but, as we can see from the bill, it is not even guaranteed that HACs will be set up, because it will be at the minister's discretion and when they are set up they will have no autonomy.

The benefits of consumer participation and structure, such as the consumer advisory councils, are well recognised and documented. The National 2001 Consumer Focus Collaboration Report stated:

Active involvement of consumers at all levels of the development, implementation and evaluation of health strategies and programs is integral to their success.

Carers SA is another of the groups that has lobbied MPs about this bill and, in its submission, it argues for a consumer and carer advisory council at each hospital. This, and other statements about the benefits of consumer participation, have been recognised in the Generational Health Review and in other health reform work by the Department of Health, but they are very poorly addressed in this bill.

Consultation is pointless unless it is genuine. I think that John Menadue envisaged a health care system which engaged and involved South Australians in controlling the destiny of their health system.

Part 8 of the bill sets out that root cause analysis will be the model for analysing adverse events. This has a hospitalcentric focus and lacks independence, as others within the same hospital will be conducting the investigations.

I am opposed to enshrining any particular method, and this specific method of investigation, into the legislation, particularly as I am not aware of any proper assessment having been done of this quite recent methodology. It is a model that places too much emphasis on doctors and, while I know nurses would have an input, they are often wrongly perceived to be less important than doctors, and their views and experiences are not listened to. I fear that any investigation would most likely listen to what the doctors have to say rather than the nurses.

Adverse incidents do need to be investigated, but internal investigation is not usually going to be the best model because it lacks real accountability. The South Australian Health Commission Act, which will be repealed by this bill, is deficient in regard to adverse events in that it focuses on the hospital with the patient effectively sidelined. We need to investigate adverse events in a way that ensures that all facts are on the table and that the investigation is thoroughly independent. With that in mind, I find it curious that the bill makes no reference to the Health and Community Service Complaints Commission. Surely, the bill should ensure that the commission and the investigation of adverse events are linked.

The Health and Community Service Complaints Commission would be an ideal and independent body to conduct investigations into adverse events, but it only investigates when affected patients contact it. Health care providers can also contact it, but it is more likely that they will be the subject of the complaints and so are unlikely to do so. I am interested in knowing what protocols will be in place as regards reporting adverse events. Clause 68 begins with the words 'If an adverse event is reported'. Surely the expectation would be that all such incidents would be reported, so I want to know why 'if' is the dominating word in that clause.

Accountability must be a major factor in legislation such as this. Is there too much power in the hands of one person? Is the centralising of the power in the hands of just the minister and his chief executive too much? Members will recall that last year I negotiated with minister Weatherill in regard to the affordable housing legislation and he consequently introduced amendments to his bill that restored a board for the Housing Trust, so that all the decision-making and power did not rest with the minister and the chief executive. This chamber supported that move because of the extra accountability that would result.

The health minister already has a great deal of power. Recent examples of the major changes to health, where the minister has made the decisions without community involvement and which have not necessarily reflected the need and wishes of the community, include the decision to build the Marjorie Jackson-Nelson hospital, based purely on the whim of the health minister and his Premier, the closure of birthing services at Modbury Hospital, and the relocation of the renal unit from the QEH to the RAH. This bill would give the minister still more power, and I have to ask whether this is really warranted. On the other hand, there are numerous instances of boards being incompetent or simply rolling over to allow the minister and his or her department to have their way while the board has grumbled a little bit in the background.

The boards of the three metropolitan health services have subcommittees which will need to be replaced once the boards are dissolved, and I wonder about the financial consequences of this. The board members are paid sitting fees, but I think the government gets very good value out of what the board members are doing for those fees. With the boards dealing with issues such as safety, quality and clinical governance—which are crucial issues for hospitals—these tasks will have to be taken up within the health service bureaucracy.

I want to know what structure the minister proposes to set up in his department to replace what the boards do now. I note that there will be advisory committees to assist the HPC, but are they a replacement of the existing board's subcommittees? If they are, will they be composed of departmental staff or volunteers or a mix? If there are volunteers, how are they to be chosen? Again, what input will the public have? Policy development is really important in the health portfolio and it is a role that board members have undertaken. So, what policy structures has the minister proposed in his department if this bill is passed?

In transferring these extra tasks and responsibilities to his department, what extra staff will be needed to take them on? What will be the extra cost? I assume that there is no-one in his department at the present time sitting around twiddling their thumbs, so there will have to be new staff. How does that compare with the fees paid to existing board members? Where will the staff be based? Will any of them be based in the regions, or will they all be Adelaide-based? The Health Performance Council is, unfortunately, the next best thing we have to the boards and they will, in turn, consult the HACs—if they exist—but it is not even mandatory for that consultation to occur.

When I was briefed by the health minister last year about this bill I told him that, on the face of it, he had prepared a convincing argument but that I would need to look at the bill and consult with others. I have done that and, as a consequence, I am ambivalent about the bill. I look forward to hearing and digesting the response the minister makes at the conclusion of the second reading. I indicate support for the second reading of the bill but also indicate that it is highly likely that I will have amendments.

The PRESIDENT: Just before we close the debate, reference was made to a member of the public being the most hated bureaucrat—or something similar to that. We have politicians standing up here making personal explanations and sometimes being very thin-skinned and, yet, they seem to think they can make comments about people who find it very hard to make personal explanations to clear their positions. If this chamber wants to be treated with respect, it should treat those outside this chamber who do not have that opportunity with respect.

The Hon. R.D. LAWSON: In relation to your ruling, Mr President, I think it was most inappropriate to describe a bureaucrat, especially the particular one named, as 'the most hated'.

Debate adjourned on motion of Hon. M. Parnell.

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