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[ Audience Applause ]
>> Thank you very much for that welcome, and thank you
for inviting me to come and speak to you today.
It's a great pleasure.
And when I look at the list of people that have spoken here,
you have obviously got a lot of pulling power.
So, it's a great pleasure, and I'm sorry
that you spent 17 days unsure of who you might be inviting,
and I'm very delighted that I am still the Health Minister
in the Gillard government because it means
that we can continue with our important work of health reform,
which is what I want to talk to you about today.
But, can I also acknowledge the traditional owners of the land,
the Noongar people, thank, of course, John and Jeannette
for introducing us and welcoming everyone.
Delighted that Professor Fiona Stanley is here, and of course,
Mike Daube, who has worked so closely with us
on our preventative health strategy.
And you obviously cross all political spectrums here.
You said in your introduction
that you had Kim Haines previously speak to you.
Today, me as the Federal Minister,
but you also have the opposition health spokesperson
from the State here, Roger Cook, and Janine Freeman,
the State Member for Nollamara, and I understand
that Senator Judith Adams is here.
I haven't seen her yet, but -- ah.
Hi, Judith.
So, we've got a broad church,
which I think is a really great sign when you want
to be an organisation that provokes thought and discussion
and debate, being able to cross not just different professional
groups and have students and leaders and others
in the community, but to have people
across the political spectrum is important, too.
I am calling my speech today,
Succeeding to Reform the Health System
because we are absolutely determined
that we will succeed in this aim.
We don't believe there is an option
to not reform the health system.
And today gives me an opportunity to talk to you
about some of the challenges
that we face in order to do that.
And, as I say, it's a great opportunity to be able to speak
to the John Curtin Institute for Public Policy.
And, I guess you would expect me, in passing,
to note that of course John Curtin, as a hero of our party,
was one of the greatest prime ministers
and while he is most fondly and profoundly remembered
for his role in protecting Australia during World War II
and forging an alliance with the United States,
he also actually played a huge role in the development
of our social services, and in particular, health care.
It was the Curtin government
that started our path towards the strong public health system
that we have today, when they introduced legislation
to establish the pharmaceutical benefits scheme.
Now, of course, a foundation block of our health system.
As Curtin's health minister, Senator Fraser said in January,
1944, and I quote, the scheme is the first step
in a long range medical and health program,
which the government proposes shall eventually include the
provision of all medical
and hospital services at the public cost.
Now it won't surprise many of you in this room to discover
that his reforms did not actually face an easy path.
They were challenged by the then British Medical Association
in the High Court and found to be unconstitutional.
It was only after a referendum,
another successful High Court challenge,
a change of government limited early implementations
and 16 years later, the PBS
that we know today was finally established.
But it was the hard work by the Curtin government,
against huge opposition from the establishment
of the medical community, that led to the PBS.
So, I tell this story just
to demonstrate how hard health reform is in Australia,
how hard it is to achieve, how hard it is to pay for,
and how hard it is to implement.
But through the tough reforms to the health system
that [Inaudible] has implemented,
whether it is the PBS, Medibank, Medicare, we now have one
of the best health systems in the world.
And whilst we should be proud of it, we can't be complacent.
Patients around Australia know
that further improvements can be made and those of us with an eye
to the future will know that the ageing population
and increasing patients with chronic diseases is going
to cause us great challenges in the future
if we leave things as they are.
That's why the government took the decision, in 2007,
that we needed to face these challenges head on.
And we undertook a major, very methodical process of reform.
We, first of all, gained evidence from the experts,
especially established Health and Hospitals Reform Commission,
especially Task Preventative Task Force,
and a group focused on primary care.
We took the major recommendations on the road,
consulting over 100 communities on their reactions
to the proposed reforms.
We released a response and negotiated a landmark agreement
with seven states and territories.
Of course, there is one absent signature on that agreement,
but I will get to that a little later.
This was followed by a federal budget providing
for our reform investments and topping it
up with direct workforce eHealth, age care,
and primary care investments.
So what we did was go through a proper policy
development process.
It was open.
It was evidence-based, and it focused
on addressing the problems of the future.
It enabled us to achieve an agreement
that would have been very hard without the years
of hard work behind it.
But, as I said, there is certainly no doubt
that we face challenges and will continue to face challenges,
just as the Curtin and Chifley governments did
over six decades ago.
And I think it's also important when we discuss this debate,
to acknowledge that our challenges are actually similar
challenges to those being faced by overseas governments, too,
such as the Obama Health Reforms in the United States
or even the Blair government's reforms to the NHS.
But we are determined to tackle these challenges
because we believe the alternative is quite a
dangerous one.
To ignore these challenges will deliver a poor outcome
for Australian patients.
We won't be able to combat the increasing rate
of chronic disease that could cripple our health services.
We will still have differing public health systems
and providers shunting patients around the system for financial,
bureaucratic, and uncoordinated reasons.
We won't be able to combat the number of medication
and other areas in our hospitals and health systems,
and the states will be under mounting pressure over time
as health costs gobble
up an ever-increasing share of their budgets.
And while I'm not going to cover each and every detail today,
I do want to go over the main features of our reform.
Reforms, which as a result of the COAG agreement with seven
of the eight states and territories in April this year,
represent some of the biggest changes to the health system
since the introduction of Medicare several decades ago.
First and foremost, our reforms are aimed
at ensuring the system is better funded, better run
and more sustainable into the future.
We will be funding a majority share of hospital costs,
including a fixed, 60% share of the efficient price
of all hospital services.
In doing so, we are taking a much greater responsibility
for health funding and a greater share of growth
in our health costs into the future.
Secondly, we want to drive important improvements
to hospital services through more accountability
and transparency than ever before.
Through activity based funding,
the commonwealth will pay hospitals for services
that they actually provide.
We'll set tough national standards,
backed by financial rewards for the states who perform well
against them, which will drive improvements in waiting times
and the quality of care.
We're introducing much greater accountability through reforms
such as the MyHospital's website,
which will show all Australians how well their hospitals
are performing.
I was delighted to be able to announce, just on the weekend,
that despite the fact that they aren't yet part
of the broader health deal,
Western Australia will now participate
in the MyHospital's website.
And all of this, of course, will be onlooking
by much more local import through local hospital networks,
and I'll get to Medicare Locals later.
In this audience, I do want to dwell a little bit
on the public policy significance of these aspects
of our reforms, just for a moment.
Take activity-based funding as an example.
Currently, the Commonwealth provides its funding
contribution for public hospitals to the states
through a block grant.
States and territories then determine how much funding
individual hospitals and health services receive.
Through the Commonwealth, the taxpayer outlay is huge.
We outlay an awful amount of money, of your money,
as taxpayers, but we don't know with any certainty what services
that funding contribution buys
or where the money actually goes.
Under activity-based funding, for the first time,
the Commonwealth will provide its funding contribution
on the basis of a number of services
that are actually delivered.
The Commonwealth share will be fixed, as I said,
at 60% of the efficient cost of each hospital service.
And efficiency will be vital, but it also means, of course,
that we are taking on the share of the growth
as the demand increases or as the population moves.
And importantly, the efficient price will be set
by an independent hospital pricing umpire,
operating completely at arm's length from the Commonwealth
and state governments.
Its role will be similar to that of the Independent Reserve Bank.
I think I wrote that before yesterday's price increase.
Maybe that's not a popular comparison to make today,
but I think the independent role is important, of course,
and they have an independent role in setting monetary policy,
and we believe that it is important
to have an independent body to set an appropriate price.
The umpire's ruling will be final
and the Commonwealth will pay its fixed,
60% share of hospital services on this basis.
This is a very significant health
and economic reform for Australia.
Even in those states where some type
of activity-based funding all ready exists,
such as my home state of Victoria,
the activity-based price is still set by government.
Charging an independent arms-length umpire
with this task will bring an unprecedented level
of transparency to the pricing of hospital services,
and therefore the government funding
which flows for these services.
And just as governments don't interfere
in the interest rate decisions of the Reserve Bank,
governments will not interfere with the decisions
of the independent umpire on hospital prices.
And just as the Reserve Bank has provided for the stability
and robustness of the Australian monetary policy for decades,
I am confident that the work
of the independent umpire will provide a similar level
of stability and robustness
for the financing of our health system.
The critical importance of moving to this system
of activity-based funding, which was one
of the key recommendations, by the way, of the National Health
and Hospitals Reform Commission, is in its capacity
to improve the efficiency and transparency
of our public hospitals.
It will improve transparency because under ABF,
we will know exactly what our massive investment,
or more correctly, what taxpayers massive investment
in hospital services is buying for the public:
how many services, where they are being delivered,
in what time, and so on.
And they will improve efficiency
because by introducing price signals into the provision
of hospital services, providers will have an incentive
to deliver services at or under an efficient price.
Of course this must go hand in hand
with strong national clinical standards and guidelines
so that efficiency doesn't ever come at the expense
of the quality of care.
And by funding our hospitals on the basis of activity,
we can ensure that the funding will follow the growth
in services delivered.
So when the population grows in a particular area,
such as the massive Perth population growth at the moment
or mining areas in WA, then the Commonwealth will pay hospitals
in those areas more money, more money that they can spend
on recruiting more doctors and more nurses
and providing the services that are needed.
As well as improving our overall efficiency,
activity-based funding can improve system performance
and the quality of services provided to patients.
For example, by explicitly linking funds allocated
to services provided, it's easy.
It allows for easy identification
of under performing providers so the cause
of that underperformance can be remedied, while lessons
from high performance can be shared.
We believe these changes
in themselves will deliver improvements to the system
in a short median term, but they will also drive very important
changes beyond that by establishing the right
incentives in the system for the Commonwealth
to also invest properly in primary care
and prevention long term.
This is because, for the first time, we will be picking
up the majority of the tab for expensive hospital treatment
if we don't get our investments in the front end right,
which brings us, I think,
to the other very major part of our reforms.
Whether it is investing in new types of care
like subacute care, including 1,300 palliative rehabilitation
and mental health beds, and very importantly, investing heavily
in prevention and primary care to keep people out of hospitals.
For example, this is through establishing more GP Super
clinics, such as the ones in Wanneroo, Coburn and Midland,
and now other sites like Rockingham,
where I was this morning,
investing in primary care infrastructure more generally,
investing in after-hours care, establishing Medicare Locals,
which will bring together
and better coordinate primary health care services,
and investing in prevention,
such as through our world-leading tobacco reforms
to introduce plain packaging of cigarettes.
I'm going to be speaking tomorrow here, in Perth as well,
about the primary care reform, so I am going
to save a little bit of that detail for then.
But I am happy, of course, to answer any questions
on those issues as well.
Fourthly, we know that we won't be able to pursue any
of these reforms if we don't have the workforce
to in-commit them.
Workforce shortages are a problem around the country
and I know that they are an acute problem in many parts
of Western Australia, and that's why we are investing much more
than ever before in training more undergraduate doctors
and nurses, in providing clinical training support
for health professionals,
including our recent announcement of $425 million
to expand clinical training capacity
into non-traditional settings,
and better supporting health professionals to work
in rural and remote areas.
And of course, reforms that will make smarter use
of our workforce, like the Medicare and PBS rights
for nurse practitioners and mid-wives,
which just came online only several days ago.
And fifthly, we want to make sure
that we modernise the health system for the future
through electronic health records for all Australians,
which will be critically important
in assisting nurse practitioners or others
to work collaboratively with our doctors
and other health professionals and ensuring information
about their patients is accessible and up to date.
We want to massively expand tele-health
through Medicare rebates for online consultations,
which I know will be of particular benefit
to the many rural and remote communities
in Western Australia.
And through innovations like eHealth and tele-health,
of course, we hope to fully utilise the power
of the national broadband network
to improve health service delivery.
And I know with our colleagues here from universities,
that the universities are all ready showing much interest
in these sorts of changes.
So even with that thumbnail sketch,
our reforms are expansive and ambitious.
They have met with an extraordinary level of support,
actually, from a wide range of stakeholders.
But as with all reforms,
they haven't been universally endorsed,
especially by our political opponents.
As was the case in John Curtin's time,
many of our reforms have met
with pretty stiff political resistance.
Despite being a former health minister,
during which time he often mused about potential benefits
of the very reforms we are pursuing,
such as the Commonwealth taking greater responsibility
for hospital funding, activity-based funding
for hospitals, and greater transparency and accountability,
the current leader of the opposition seems determined
to be a wrecker when it comes to these reforms.
Remarkably, the coalition voted in the lower house last week
against legislation to establish a permanent Australian
Commission on Safety and Quality in Health Care,
the very commission, in fact, that Mister Abbott set
up on a temporary basis when he was the minister.
The permanent Safety and Quality Commission will work
to drive improvements in safety and quality
of health care provided in our hospitals
and in other health settings, and particularly,
for some of you who may not be working in hospitals
or following this in detail,
let me just give you a little snapshot of why something
like this is so important.
One in thirty adults who goes into hospital,
contracts an infection while they are there.
Twelve thousand of these people acquire bloodstream infections,
and about a quarter of those patients die, a figure which is
around twice the national road toll.
So this is not a small problem that we are trying to tackle,
and it's just one of them that the Quality
and Safety Commission can help with.
And yet, the federal liberal and national parties voted
against the establishment of a permanent body
to address these problems.
But in good news from our new Parliament, I was very pleased
that despite this approach from the liberal opposition,
the bill still passed the lower house with the support
of all six cross benches, the first bill
in the current Parliament to do so.
So, whilst I do expect some more political intransigents
from the federal opposition, we do hope for a fair hearing
and approach from the cross benches
as we have seen last week.
We haven't let, of course, the negativity
from the opposition put us off.
Since the COAG agreement in April, we have been very hard
at work, sleeves rolled up, getting down to the business
of implementing and bedding down these reforms.
As I said, despite the challenges we face
in the current Parliament, the legislation
of our reforms is going full steam ahead,
as well as passing the Safety and Quality bill,
we also passed a bill
to establish the National Preventative Health Agency
legislation last week, and the treasurer introduced the federal
financial relations reforms, which provide
that all important framework for health reforms.
Medicare Locals, the primary health care organisations
which will help drive better integration and coordination
of primary care services, will be one step closer
when we open expressions of interest for the first of these
in the very near future.
We have been working steadily on the establishment
of local hospital networks with the states and territories,
and our investments in hospitals and emergency departments,
elective surgery and subacute beds are all ready rolling
out across the country.
In fact, we have all ready announced hundreds
of new subacute beds across the country.
Although, unfortunately, none here, yet, in Western Australia,
which of course brings me to the elephant in the room.
I am, of course, disappointed that,
although Western Australia has agreed to health reforms,
it hasn't yet signed up to them like the other states have.
I am disappointed because as Health Minister,
each time I come to Western Australia,
I see how the state's health system could benefit
from the reforms that we are pursuing elsewhere and the money
that is on the table to go with them.
I see problems that are continuing to happen
in the health system, the stories that don't stop,
deaths in regional hospitals
that have prompted investigations
into whether care was appropriate, delays in scanning
and surgery for breast cancer, capital works projects delayed,
health IT projects delayed or criticised
by the Auditor-General, and elective surgery
and emergency departments' targets not being met.
Now, I don't pretend for a second that the rest
of the country doesn't have problems.
Of course they do.
But the point is, courtesy
of the COAG Health Reform Agreement, every other state
and territory is on the path to trying to fix them.
Western Australia is not.
It is also important, I think,
to correct some other misconceptions
that have been allowed to flourish in this debate.
Perhaps most significantly is the argument
that the financial reforms
which underpin our health reforms are merely an accounting
trick, which results in shuffling the same pool
of GST revenue from one level of government
to another for no net gain.
I do know that the GST is an issue that evokes a lot
of passion here in Western Australia, but I do need
to tell you that this view of our reforms simply isn't backed
up by the facts and I would
like to take the opportunity to explain.
Our proposals will fundamentally change the way health care is
financed in Australia.
Hospital costs are currently growing at almost 10% per year.
GST revenue, which helps to finance these costs,
is currently growing at around 6% to 7% per year.
By taking on responsibility for funding 60%
of these growing costs,
the Commonwealth will take a much greater share
of health costs into the future once the GST transfer is
locked in.
This will relieve states and territories
of at least $15 billion worth of expenditure
over the next 10 years, by our estimates,
or around $1.6 billion here in Western Australia.
And the reforms can also have a direct benefit
for patients right now.
We have got $351 million dollars ready to inject
into Western Australian hospitals
to deliver more subacute beds, faster elective surgery
and emergency department waiting times.
As the health minister, I confess to some frustration
at the current stand-off.
Both the Premier and the Health Minister
in Western Australia have told us several times
that they support the health content of our reforms.
No doubt they agree with the health content
because they know our health reforms will benefit West
Australian patients or think that there are benefits
in national standards, targets and comparisons.
Obviously, the government is still considering its options
if getting Western Australia to come
into the health deal simply does not prove to be possible.
But we hope it will be possible because we want all
of the country to benefit from the improvements to health
and hospital services that we are confident our reforms will
deliver, and we believe the best way to do this is in partnership
with the states and territories.
All of us understand that this great state deserves
to be looked after, deserves its fair share
from the federal government, and I completely respect
that West Australians will stand up for themselves
and that has certainly been a feature of our federation
since its rocky inception in this state.
I understand West Australians wanting
to fight for their fair share.
No one understood this better than John Curtin himself,
someone who was strongly against the move for succession
in the 1930s, but someone who still argued
that Western Australia should get its fair share.
What worries me is that Western Australia might miss
out on its fair share if the current stand-off
over health reform is not resolved.
Premier Barnett has said recently he is content
with Western Australia having a separate health system
from the rest of the country,
but that means Western Australia won't get the benefit
of increased federal funding, won't get the benefit
of activity-based funding, and won't get the other benefits
that flow from our reforms.
Premier Barnett keeps saying that this isn't an issue
about health, it's just about the GST.
But the truth is, it is about health and the future well-being
of the Western Australian community.
I believe that this is an opportunity
that is too good to be missed.
I hope that the opportunity will be seized,
and I very much look forward to continuing to work
with the West Australian government to find a way
through our current impasse.
Thank you for having me here today
and I am happy to take questions.
[ Audience Applause ]
>> Thanks very much.
We have got a couple of roving microphones floating
around somewhere soon so can we please indicate --
put your hand up and say who you are and where you are from,
just in case you are a plant from John Barnett's office.
I'm sure you are not.
We do have various people from the public service as well,
so feel free to ask questions and this is rearing to go.
So, we've got one over here.
>> Hello, Minister.
I am Linda Shields.
I am the Professor of Paediatric
and Child Health Nursing at Curtin.
I have heard you speak on this before
and I have read many of the documents.
One of the things that concerns nursing, in particular,
and those of us who are working in community,
is that there seems to be a misunderstanding
between primary care and primary health care.
And your model of funding primary care,
treating peace, would reflect that.
Can you comment on that?
>> Thank you.
Yes. That's one of the things that I have a very strong memory
of from the first days of when I became the opposition health
spokesperson, a person without a health background.
That was many years ago when that happened,
and I can remember saying to one of my advisors,
why are people talking about primary care
and primary health care.
What difference does it make?
Aren't we talking about the first point of call
that people come to in the community?
And, luckily, I had a very wise advisor who said, no, no, no.
There's a lot of politics in this.
So that's about the GPs and it's
about the other health professionals.
I must admit, I don't care, especially,
for the terminology one way or the other, but I do disagree
with your view that our funding is just going to GPs.
In fact, you know, from the first of November, Monday,
this week, the first changes for new categories
of health professionals to be able
to directly access the Medicare Benefit Schedule and the PBS,
what were instigated only from our work and against a lot
of opposition, because we saw that nurses
and midwives were sufficiently qualified in this country
to be entitled to access that sort of funding.
And therefore, for us to support what would be a growing area
of practice for many nurses who perhaps have not considered it
as an option because of the financial barriers
that there were.
But, I think there are two sides to this argument.
I think we should reform the system to allow nurses
and midwives and other allied health professionals
to get more recognition for their skills,
but I am unapologetic about wanting to support GPs.
We actually have a good system of GPs in Australia.
We have very high trust.
Most people have a regular GP, not all by any means,
and some big exceptions as Fiona would be aware
of in our indigenous communities.
They are a good conduit and referral
to other health professionals and they are very well trained,
so trying to reform the system that maintains and supports
and builds on the strengths of what GPs do,
but actually opens the doors a bit wider
for other health professionals that have been left
out is a balancing act, but I think the view
that we are only doing things through GPs just doesn't stand
up to the quite historic changes
that were implemented just this week.
>> Thank you.
Care to stand?
>> It wouldn't be right to come to Perth
without Fiona asking a question.
>> Thanks very much, Nicola,
and I just commend the holistic nature of the health reforms
that you have outlined and that are on the table
because you are attempting to address the pathways
into disease as well as treating the,
or coping with the huge levels of chronic disease
and the ageing of the population, et cetera,
and I think that it is --
the holistic nature of that is great.
And if I can just make a supportive statement to Linda
that I am very, very supportive of nurses
and midwives having a greater role and I think
that that is part of the solution,
not just in remote communities, but actually
in the general community, and that there is an
over medicalisation of births, for example, which has led
to unnecessary cesarean sections at a rising rate
with the highest rate in Western Australian cesarean sections.
Probably at least half of these are not necessary.
And if there was a greater role
of community midwives, they wouldn't happen.
And I think -- I do think that's a --
we have probably done one of the best studies on home births
in Australia many years ago to show
that they were incredibly responsibly handled by midwives
and I do think that those data need to be looked at
and obstetricians have to relinquish low-risk deliveries
to midwives and trust that they will be good outcomes.
But that's -- I do think that that is terrific,
that you have enabled those supports
for midwives and nurses to happen.
My questions sort of relate to the quality in evidence-based,
which I am really pleased
that you have got a commission to look at.
>> They're going through the lower house.
I don't want us to get ahead of ourselves.
We haven't got it through the Senate, yet.
>> But, I mean --
>> Perhaps Judith will help us with that.
>> I mean, looking at the evidence that we have
on the effects of health care, quite a proportion
of what we do has either no evidence of effectiveness
or there may even be evidence of harm,
and yet we continue to do it.
I'm not quite sure of the proportion in other areas,
but in the paediatric area and the obstetric area,
something like 70% of the drugs prescribed to pregnant women,
and about 80% of the drugs prescribed to children,
have no randomised control trial evidence of effectiveness
or harm, and yet are increasingly being used.
And so I think, you know, it is absolutely crucial
that we get the best evidence that we can around that.
And I think that, therefore, that's another way
of terrific cost control if we can eradicate those things
which are harmful, my God, that's really important,
but those things which are useless, as well.
And I think it would be very interesting to see how
that committee is going to function
and I would be very interested
if you could just give us a bit on that.
And the second comment that I guess wanted to make,
related to that, I mean, you know --
>> I'm going to be struggling to remember any more questions
if you go much further.
>> I'm sorry.
I was going to ask about eHealth because eHealth,
to a certain extent, is going to help with that enormously,
and that is that we have, as you know,
a system of record linkage here in Western Australia,
to be able to link health records to things like the PBS,
and we have the ability therefore
for pharmacovigilance second to none in the world.
And yet we have been blocked getting Medicare data
and PBS data by the Commonwealth for reasons I don't understand.
And if they are to do with privacy, we haven't had a breach
in 35 years of record linkage in West Australia.
So, I don't know if you can answer that question,
but it is very frustrating that we have done the feasibility
to show that we have a wonderful way of getting evaluation
of adverse effects of drugs and we are being stopped to do it.
>> Yeah. Thank you.
I will try and cover a range of those.
Obviously, on eHealth,
we do think that there is an enormous well to be opened up
and it is true to say that governments
of all colors before us have really not been prepared
to bite the bullet and plan far enough ahead.
And it is hideously complex.
It is hideously expensive.
But it is hideously important and we have been able
to get the money to do that
and we have the determination to do that.
But you touched upon the privacy issues.
There is a big -- well, I don't know that it is a big group.
There is a noisy group of people who are very concerned
about the privacy consequences and I do think it is one
of those areas where you can derail what is a very positive
reform if you don't move carefully to be able
to reassure people at every stage of the way
that it will be patient-controlled,
that you'll be protected, that if it is going to be used
for research, that it is de-identified,
all those sorts of things.
And I think those assurances are not difficult to give,
but I think we need to work through the process
of building confidence in it because it is one
of those things that if something went wrong early,
you would kill it forever.
When actually, we, I think,
have a huge opportunity in front of us.
I remember being briefed very early on about the request
that had been made for the data and I think the reticence,
I can't answer for previous Commonwealth governments,
was always about not having to take this next step
for electronic records either, and not really having thought
through a decision about whether it was going to be sort
of government-owned information or patient-owned information.
We have been very clear that we want it
to be patient information
that your approved health professional can access
or other people, if you agree, can access,
and what we actually know is
that people get very confident very quickly.
People with chronic diseases who actually want a range
of health professionals to have access
to their information will give that permission quickly
and they will become the advocates in the community.
I just think it is one of those things where you have
to be prepared to take people along with you,
which means it's a bit frustrating
if you have had a vision from a long time ago
about where you could be.
But I am optimistic that we can keep working
on those issues together.
[Inaudible Dialogue]
>> Yeah, well the Safety and Quality Commission,
many of you have worked with all ready in its temporary format.
It has been running for four years
as a temporary organisation.
It has done some good work.
It doesn't have the authority that it would have
as an independent body that all the states
and territories have signed on to.
That's why we would like it to be set up as a permanent body
with its permanent budget at arm's length from government,
so that its guidelines, its rules,
its range of other things actually need to be adhered to,
particularly for the states and territories, who at the moment,
although they had agreed to the temporary body, can say well,
that's really, that's part of the Commonwealth's Department
of Health, rather than a sort
of stand-alone credible, quality body.
And the legislation specifies the types of people
who should be on that body and how it would be set up.
I can easily get that to you.
But I think it's a good opportunity to be able
to really give it some teeth.
I think it has done a good job
in the circumstances it has been in, but it is time now
to let it grow to the next stage of development, I think.
>> [Inaudible]
>> Thank you.
Jill Downey, Pro Vice-Chancellor of Health Sciences at Curtain.
Thank you, Vessley [Assumed Spelling],
for your presentation today
and congratulations on the reform agenda.
Certainly, we believe moving in the right direction.
I am very interested in clinical placements
for our health professional students that will make
up the workforce and I think the implementation
of Health Workforce Australia has been very widely supported
and very much appreciated, not only within our university,
but I know from universities
across Australia and health agencies.
Certainly the 420 or so million dollars that you have talked
about being distributed has been welcomed
and it certainly is going to fund growth
for student clinical places.
Sometimes what happens with policy, though,
is that there are unintended consequences of that policy,
and while that policy is funding growth for clinical placements,
one of the things that is happening is
that private organisations and public, who take our students
for clinical places, are now asking for additional funds
to sort of match what the Commonwealth is putting
into the new places for growth.
That is an extreme burden, which won't be able to be borne by any
of the universities that I know of,
and certainly it is a concern for PBCs Australia.
Are you able to comment on that?
Is the funding for our previous or old clinical places,
as well as our new, is that going to come in the longer term
from the 60% of funding for education and research
that the Commonwealth will fund?
>> Look, I think -- thank you for that question
because I think it is a very foolish approach
if organisations are now starting to revert to --
I mean, one of the reasons in the past that the Commonwealth,
not what the [Inaudible] government,
but was never persuaded to put money of its own,
Commonwealth taxpayer's money, into the training system was
because they argued that the tertiary funding
that was provided to universities
and states was meant to include placement money,
money for clinical placements,
and that those arrangements have been sorted out for a long time.
What we are seeing, because we have got such a shortage
of so many health professionals
and there are a much larger number of people being trained,
which is good, is everybody feeling squeezed.
Universities feeling they're not getting enough money,
hospitals feeling they're not getting enough money
for their work, and the thing that always gets squeezed is
who is going to actually provide for the training
for the new interns or for the, you know,
psychology placements or for others.
So, we saw this critical need
and it was something we invested money in very early on.
So, it was in a 2008 COAG agreement
where we said we're not planning properly.
We don't know where all the placements are.
We don't know how many people need placements.
The Commonwealth is prepared to fund a bigger share of it,
but you have got to maintain your effort,
the states and other players.
So, all the money that we have invested
so far has been to increase capacity.
Most of it is being spent on infrastructure
so that there is more facilities in primary care
and simulation facilities at universities
and in private hospitals and in some more creative settings,
even in our public hospitals.
But we are just going to be on a downward spiral
if everyone goes oh, we have finally got some more money we
needed, and now we want more money as well.
People will never be able to keep up.
But, the longer term change will be assisted
by the 60% funding because, although I focused on the sort
of activity-based funding and giving the examples
of paying per hospital procedure, we have agreed,
for the first time, that we should pay 60% of all training
and education costs in our hospitals as well,
60% of research, and 60% of capital user costs.
So it is actually 60% of all of these things that, previously,
were just in the big bucket and you were expected to do,
and we believe it is a way of, again,
being able to have a bit more transparency,
that people should properly allocate for training as part
of what you need to do in a hospital
or other health service.
But I think we might have some rough times ahead
because we do have, like you in Western Australia,
a very big increase of medical graduates coming online,
we want more nursing students and others.
We're going to have to find creative ways
to make sure they get proper training experience
in different settings where we know we then expect
and want people to go and work.
And that means, you know, having proper training systems
in age care, you know, facilities,
which we have never done before, but we actually need thousands
of health professionals working in aged care.
So, we had some money in the budget for that.
So I think we are trying to be creative
in the way we expand the settings.
We're going to need a lot of good will to continue, though,
from the hospitals and other health service providers
or the whole system really will fall apart.
>> Hello. My name is Ellis Moncusi [Assumed Spelling].
I am just a student from EWA.
>> Not just a student -- very precious, our students.
>> Yeah, well.
I'm not as esteemed as yourself, I don't think,
in my student career as yet.
>> They will be more help to a patient, however.
[Laughter]
>> I doubt it.
[Laughter] I have a couple of questions, if you don't mind,
and they both hit on a couple of topics you talked about there.
The first is to do with the idea of federalism and I think,
although you say your background is not in health, it is in law,
what is your concept of, you know, federalism?
Is this an outmoded concept that is no longer applicable
to Australia as we move towards things like this
where the Commonwealth funds more of our services
that are delivered to Australians and the states?
And secondly, your analogy of the activity-based funding body
that sets the prices, the analogy with that
to the Reserve Bank, and you mentioned, you know,
the transparency aspect, too, but also,
the Reserve Bank obviously has the accountability aspect
as well, if it is [Inaudible] criteria
of the inflation target.
I wonder, where is the accountability,
I should say, of your body?
>> Okay. Thank you.
Well, I mean, it would be set up as a body that still needs
to come and present, for example, to senate estimates.
Judith, who is here, knows that it is a process to be able
to hold organisations to account,
have proper audit abilities, all of those sorts of things.
It is true that it won't have as simple measure
as the Reserve Bank about where inflation is
or how the economy is traveling because health is going
to be a complex beast and the way you price all
of your services is pretty important,
and the legislation would not get through the Parliament,
nor would we seek it to try to get through the Parliament
if it didn't have a whole lot of, you know,
safety valves built in there.
There will have to be ways that states and territories
and others can indicate
if something gets completely out of whack.
But, the contrast is the system we have now.
Based, for example, in Victoria, when Jeff Kennett decided
to introduce activity-based funding, closed a whole heap
of hospitals, said here's a pot of money.
At the moment, we know this much activity happens.
Divide that this way.
Right, that's what we'll pay for each type of activity.
Never actually calculated on the basis
of how many nursing hours do you need for something,
how many rehabilitation hours do you need,
what sort of medical intervention
or equipment do you need.
That sort of rigorous process, we think,
needs to be put in place.
My view of federalism is that if you were --
if we, as a room now, were the, you know, the founding mothers
and fathers of federation, would you try
to create the system the way it is now,
with the knowledge we have now?
Probably not.
But, we have what we have,
and I actually think there are quite a few strengths
in federation.
I think, although there are occasional hiccups,
and I regard us as being in an occasional hiccup at the moment
with Western Australia, by and large, it's a good opportunity
to be able to test out and try out differences,
mostly states actually share their information quite well
and when something has worked well in one state,
other states are not shy about adopting it.
But, improving what can work nationally,
especially with new technology, especially with new information.
There's no reason that, you know,
whatever the appropriate clinical guidelines are
for heart transplant should be different in Perth
to what it is going to be in Brisbane,
and trying to recreate some of those things in every state
and territory is just a bit silly.
So, I am kind of in the middle of the argument.
I think that we could do more things nationally
that make sense, but I don't believe
that we should do everything nationally.
I have no aspiration for taking over the states and I think
that there is many strengths in what the states can do.
But getting that balance right is always difficult
and that is probably why we are in the healthy argument
that we are in at the moment,
which I hope will have a healthy ending.
>> I've got one question here.
>> Neil Fong from the Curtain Health Research Institute.
Nicola, you have talked a lot about the reforms
and I think you have given us a really good overview
of the reforms, in a sense, individually.
And you have said there has been very good support,
even though the state has not actually signed
on to the health reforms.
I am just wondering whether you could spend a little bit
of time articulating how some
of the reforms actually fit together
because if there is some criticism,
it might be that they are not flowing together,
and in particular, you might like to expound
on the connection between the local hospital networks
and the Medicare Locals and how
that is actually going to make a difference.
And in particular, maybe bring in the ABF, as well,
as a mechanism to actually drive the change in spend
of health dollars because, at the moment, if you just looked
at ABF, and you're going to spend 60%,
no one has actually said -- it's kind of like an unlimited amount
that you could potentially spend
in hospital services unless you were going
to actually have explicit purchasing decisions
overlying that.
So I'm just wondering if you could kind of,
maybe just spend a little bit of time explaining
that because we are interested in the systematic reform.
>> Yep. Sure.
I mean, the real benefit, I see, in the activity-based funding,
provided you build in protections
which we have committed to for smaller regional hospitals,
which we'll not necessarily ever be able to operate, excuse me,
at the same, you know, efficient prices you have
for a national price.
The real beauty is not just in knowing what you are doing
in the hospital, but means that, for the first time,
there will be a health minister, a finance minister,
and a treasurer, at least in one jurisdiction, who will be able
to say hang on, it doesn't make sense for us
to keep spending a growing amount of money in hospitals,
where if we just bit the bullet and spent a bit more
in primary care, we could actually reduce demand
on our hospitals.
We have never had that before.
We have never had, around one cabinet table in the country,
anyone who has that mix of financial incentives
in the one room, because for the states and territories,
they have got no choice.
They have got to meet the hospital demand.
They get beaten around the head when things don't work
and they just have to find a way to make it work.
And some of them, then, do look at things outside hospital
to help relieve demand, but they are really only doing it
because it's the way to try
to take some pressure off themselves.
At the Commonwealth level,
where we have got the major investments in primary care,
it has always been impossible to mount the argument that just
because it is good for better health outcomes,
that it is financially sensible, because if we reduce pressure
on our hospitals that we don't currently fund
for any activity-base,
that's all we're doing is giving a windfall to the states
because we have all ready agreed
to their block amounts of funding.
So, that should not be underestimated
as a very big reform in how you can make sensible decisions
around health spending and health outcomes.
I think that the fact that we are trying to do so many things
in our reforms, and that we are asked to explain each of them,
does sometimes mean you don't get that whole picture.
So, for the Medicare Locals, which will be able
to be established here in Western Australia
because they are Commonwealth funded,
they are for GP services, their best impact would be,
if they've got the support of the states and territories
as well, but nevertheless, they could be implemented.
Our intention is that the Medicare Locals main job will be
to get, and I think it goes back to the very first question,
much better and stronger relationships
between different types of primary care givers,
different -- so whether it's GPs, whether it's nurses,
whether it's community nursing,
whether it's mental health providers,
whether it's aboriginal medical services, we've got nothing
at the moment that can try to bring those services together,
not to be run together, but to coordinate with each other
and complement each other, and to plan for local area
and say hang on, in our local area,
we don't have any psychologists
and we have no podiatrists or a paediatrician.
What can we do to actually fill in those gaps?
What can we do to plan for keeping our community healthy?
What sort of preventative health initiatives could we be?
It's really hot here in WA if you've all ready got flies.
So, that's really important.
And we have had an argument with people saying look,
if you are putting local hospital networks
in smaller regional areas, is it the most sensible thing
to put them in a partnership with primary care organisations
as well, look after the whole community's health care needs.
And I think, much longer term, that is probably a good idea.
But I know if you did it now,
that all of those very desperate primary --
now I'm worried about getting it the wrong way around.
Everybody working in the primary care sector,
primary health care sector -- anyway, you know what I mean,
will just get swallowed up by the demands of the hospitals
and the better organised advocacy for hospitals.
So, I say that you have to sort
of have those more regionalised structures starting.
I hope if they work well, then maybe at some point
in the future, you would join them and you would actually,
genuinely be planning for what sort of hospital needs there are
in a broader region and what sort
of other health care needs there are in a region,
but I think we have got a fair bit of capacity building
to do first, before we can do that.
So, I mean, that doesn't give you the whole broad brush,
but hopefully it might explain it for those.
How are we doing?
>> We have time for maybe one last one.
Have you got one?
Here you go.
One last one.
>> Minister, hello.
Barbara Horner, Centre for Research
on Ageing at Curtin University.
Thank you for your presentation.
It has been very interesting and very useful
to hear an explanation of how all of those components
of the reform pull together.
My question relates to your ageing portfolio.
It is a very interesting and a very difficult
and challenging sector, and we are seeing some great reforms
and we are seeing industry providers working very,
very hard to do things well and to do things differently,
and we probably still have one of the best systems
that we could possibly have, even though it still has areas
of frustration for many of us.
I am wondering if there is going to be an opportunity for funding
to be designated for some demonstration models
of new models of care, new ways to deliver age-care services,
particularly in the residential area.
It is an area that we have had some encouragement to work on,
but without some designated funding to some of the providers
who really have some fantastic and creative ideas,
it is quite difficult to put some of those reforms in place.
>> Yeah, thank you.
That's a good suggestion.
I might just make sure that one of my staff
who is here grabs a card from you
because models would be useful to talk to Mark Butler,
my colleague, who is the Minister
for Mental Health and Ageing.
We are interested in looking at innovative models
and you are probably aware, in this audience,
that we have the Productivity Commission currently undertaking
a review of the age-care sector,
and I think there are some pretty difficult issues
about how that sector is going to be viable into the future,
meet the demands of the population,
turn itself into a different type of service into the future
as baby boomers have different expectations
and all sorts of other things.
One of the, not very often spoken about,
changes that was agreed to as part of COAG is that we,
at the Commonwealth level,
are taking on full responsibility
for aged services.
Obviously, we have all ready always been funding the
residential aged-care,
but we have only partly funding HAC services before.
And part of the reason we were so determined to take
over that completely in aged care,
is we feel that there is a broad spectrum
between what a very targeted community care package can
provide and what very intensive residential care can provide.
And no one has done much work about what could go
in the middle, and might be a better type of care.
What could you do in providing more care at home?
Should we separate out the cost of care and the cost
of accommodation because they are two different things?
Are there other ways to look at this?
And, we think the Productivity Commission will give us a lot
of information, but we are not thinking they will give us all
the ideas.
So, I know Mark is very keen to hear about different models,
talk with different researchers, see what other ideas there are,
and we believe that we will have to look pretty creatively.
And this term's agenda, for me, is trying to bed down all
of the extensive reforms that we have.
And we have specifically tasked Mark as an additional minister
in the portfolio with two of the areas
where we need some creative, new change, in mental health
and in aged care, so that we can keep the momentum moving,
where there are other needs for reform,
but we can still concentrate on the very big implementation task
that we have for the reforms that have all ready been agreed.
So, Chris might duck over and get your card, or Jesse,
I think, is in the back there to do it.
Thank you.
[ Audience Applause ]