Published: 29 May 2018

Legislative Council Wednesday 23 May 2018

Ms FORREST  (Murchison) - Mr President, provision of accessible quality healthcare is a fundamental responsibility of the state government.  It is always a challenging area because demand will always outstrip capacity.  That becomes evident at some peak demand times, such as during the winter in Tasmania, when medical admissions to our acute health services increase significantly.

It can create the perfect storm:  with a particularly severe flu season, as in 2017, staff as well as patients can be severely ill for extended periods.  This is why it is vital to ensure structures are right within our health services to enable them to adapt and adjust to absorb increases in demand capable of being managed.  We simply cannot achieve this if we do not have adequate inpatient beds staffed by adequate numbers of suitably qualified nurses backed up by medical staff who are equally skilled and qualified.

Nurses need to be paid a wage commensurate with what their mainland colleagues are paid, bearing in mind living costs and other relevant comparisons.  If we do not, we will not retain the specialist nurses needed to ensure delivery of acute health services, which is the focus of this bill.  We need to be able to meet the health needs of Tasmanians.

This bill does nothing to address this.  Indeed it is not intended to, but any change we make needs to be made with this foremost in our minds, as one will not work without the other.

We also need to ensure our acute health services employ enough allied health professionals   including physiotherapists, dieticians, pharmacists, occupational therapists, social workers et cetera - to ensure smooth flow through in the acute health service and timely discharge back into the community and primary healthcare.

I also note the continued broad support from within the health system and outside for the one Tasmanian health service system in principle.

We need to get the operating structure right and not keep changing it as people become change-weary.  Continually changing it creates a whole heap of additional challenges.  We need to get it right.  Is this right?  Time will tell.

Mr Finch - What about those in the education system?

Ms  FORREST  - Yes.  We need a long-term agreed plan for health.  I know we have the minister's One State, One Health System, Better Outcomes plan, which is aiming toward that, but we still have to see significant change in the structure of delivering it, to achieve it.  We need to have a long-term plan so we do not see constant change.  This change is necessary - I am not saying it is not, it is.  It is very clear from all the feedback received from the member for Hobart's inquiry into acute health services, but the real challenge is with governance, and this is seeking to address that.  We have to do everything we can to ensure it is right.

I believe overall a state approach is essential, with local decision-making and input at the service delivery level an imperative.  This does not mean that every local level will make decisions about what services are provided and where.  That is not what I am talking about.  I am talking about the local input to deal with local challenges and specific local issues. For example, the Burnie hospital has different challenges to the Royal Hobart Hospital.  We need to have some flexibility around that and I hope this will provide that.  I will be asking the Leader for some more detail on how that will be achieved.

One of the potential failings I see with the bill before us is that there is no clear assurance on this local input and decision-making at the service and delivery level.  I asked this of the minister in our briefing.  I appreciate the opportunity to have had this briefing with the minister this morning, and also access to the secretary previously for a few individual briefings on the bill.  He agreed that there is no clear local decision-making capacity reflected in the bill.  His reasons for that are that you do not want to create a system where you are boxed in because that creates further problems down the track.  I want an assurance from the Leader, in her reply, about how this is actually going to work.  I have spoken to the secretary previously about this and I think he is well prepared, one would hope, and so are his other helpers there.

The provisions in the bill provide very little detail about who will make up the executive.  Effectively, this could enable the decision-making to be left to the secretary and the executive, who could be one person.  This bill is silent on that.  I asked the Leader to make it clear in her response that this will not be the case and that local clinical leadership and decision-making, through membership of the executive, will occur.  In her second reading speech, the Leader spoke about a 'lean executive' - of course you want a lean executive.  We do not want money spent on administration that should be spent on delivering patient services.  But you also need to be sure you are not so lean that the appropriate voices are not being heard and the decisions are being made from afar, which is what we have seen in the past.  It makes it very difficult:  you end up finding that some of these decisions seem to be made at a local level, far away from Hobart, because they find themselves in the position where the system is not working for them.  It needs to be a system that clearly enables that, but the bill is silent so I seek some assurance from the Leader that will be the process. 

There is also very little detail about the local advisory groups, their make-up and role.  In the briefing, it was helpful today to hear that the current advisory groups and community health groups already in our community - though I do not have constant or regular communication with members of the north-west one - will be transitioned into this legislative framework, creating some extra benefits.  Once they are in a legislative framework, more information can be shared with them to assist them in their advisory role.  That is a positive thing, but it is not apparent from the bill that this is the case, so again I seek assurance from the Leader that will occur.  As the minister said in the briefing, if there is a particular issue with a particular area, whether in one of the small rural hospitals or one of our four major hospitals, an advisory group could be formed for a defined period to address or to advise on a particular challenge or issue.  I would like the Leader to address some of the things mentioned in the briefing today regarding local advisory groups.

The Leader claimed this bill strikes the right balance between setting strategy and direction in health for the whole state while giving local facilities better capacity for local decision-making to deliver high-quality services to patients and solve local problems as they arise.

She said this bill lays the foundations.  While this is true, after all the feedback to Government Administration Committee A on acute health services, and the length of time clinicians have been expressing concern about the government's model under the current arrangements, we need more detail about these very genuine concerns and how they are being addressed.  We are fixing the structure, but it needs to be very clear how it will address these real concerns of governance.  It has been an ongoing challenge.

It is sad when people feel they are forced to go to the media to raise these concerns, when they feel they have been bashing their heads against the wall for some time.  A lot of that was to do with the very unclear reporting structure, which has now been streamlined.  The secretary is now the go-to person.  It is clear that is where the responsibility lies, and then with the minister.  There was a dual reporting structure.  Sometimes it was claimed they were both the responsible reporting person; other times it was nobody so people had nowhere to go.  It has been a serious challenge that directly impacted on service delivery and thus patient care.

The Leader suggested in her second reading speech that the secretary is currently consulting with the Tasmanian Health Service on changes that need to be made to support local decision making, and has consulted with key representatives, including the Australian Medical Association and the Australian Nursing and Midwifery Federation; THS statewide executive; senior executives from the Royal Hobart Hospital, Launceston General Hospital, the North West Regional Hospital; consumer representatives from the south, north and north-west; and the Health and Community Services Union, the Community and Public Sector Union and the Medical Health Council of Tasmania.  I know they all support the intent of the bill.

There is broader gamut to preserve and continue to build the core elements of a single statewide service and the clear role delineation across the four hospitals.  I support that and have done so for a very long time.  I tried many moons ago, in a previous government, to establish one health service but with local input.  As the member for Rosevears said, it is sometimes three steps back and one step forward.  Sometimes it takes a while to get there.

I agree with the Leader that within our statewide health system the large majority of services are delivered locally and the system must support local operational decision-making.  The system must support local decision-making and help our health facilities respond to the different health needs of the local communities - not completely different but there are nuances in each area.

The Leader acknowledged that we need to do this, and we need to empower decision-makers in our hospitals by giving them the authority and the tools they need to do their jobs.  This includes a clear organisational structure, budgets and staffing establishments that enable decisions at a local service level where they can be managed within these parameters and improved business reporting.  I agree with these sentiments and ask for more clarity on the make-up of the executive and how this local operational clinical decision-making will be assured.

I know there is support in the medical profession for this bill because it addresses many of the governance issues that have caused so many problems.  We need more clarity and detail about the local clinical input and how that will be achieved.

The bill provides for the THS to be managed by the executive of the State Service officers, appointed by the secretary.  The executive will be responsible to the secretary for the administration and management of the THS and the performance of the THS.  The functions of the executive include management and monitoring and reporting to the secretary on the administration and financial performance of the THS. 

That is important because there is only so much money we can put into health.  Health could consume the whole state budget, and health inflation rises at a much higher rate than normal inflation. 

We do need to be able to manage it within a budget and is always the challenge.  What is missing is the need for the executive to also have the function of, and responsibility for, the collection, monitoring and reporting of the performance of the THS in delivering good patient outcomes using monitoring and reporting outcomes focused on performance information in the delivery of the health services within the THS.

I note one requirement in the bill is for the service level agreement to have performance information.  There is no requirement there for it to be outcomes-focused.  This is a vital aspect of service delivery.  While the framework is set up in the service level agreement, there is not a focus on the patient outcomes.

We can count as many hip operations and knee replacements - and many other surgical procedures and medical treatments - as we like, but if these patients do not get the outcome they are looking for and do not return to good health or full mobility after their joint replacement, for example, we are not actually delivering the service we should be.

Mr Valentine - We cannot measure how well the delivery of the service is.

Ms  FORREST  - That is right.  If they end up being recycled back through the acute health system, that is money that should not be needed there.  That should be money other people who require the acute health system can access.  This is a vital aspect of service delivery which I would argue is as important as the financial performance.  I foreshadow an amendment that provides for this role and responsibility of the executive.  I appreciate the assistance I have had with the Leader's advisors and the secretary on working through this.

Of course appropriate outcome measures will need to be agreed and in line with Commonwealth reporting requirements, but there is nothing to stop Tasmania leading the way in this area and really focusing on getting the best patient outcomes we can and hopefully reducing demand on our acute health services as a result.

If the focus is on good patient outcomes that do not see them re-entering the acute health service because of a problem not fixed in the first place, we will have achieved a great deal.  Without that focus, it can be lost in the financial aspects.  I will speak more on this in the Committee stage. 

I support the principle of this bill and hope it can bring clarity and certainty to those delivering our acute health services.  I thank them for their work.  I have been in the system for a very long time and know how hard our nurses, medical practitioners and doctors work within the system.  When you are worn out from working many shifts and receive a call asking whether you can come in, sometimes you think, 'No, I am too tired', but you go in because you know what it is like to be there and not have someone come and help you.  The issue of overtime and those sort of things can be explored at a later time, but nurses and doctors have their patients' health and welfare outcomes foremost in their minds with all the care they provide.  The last thing I want is to see someone not receive the care they should because of lack of resources, either human or other, so I thank them and acknowledge the hard work they do.

We must remain focused on adequately funding and staffing our health facilities and keeping patients at the centre of all our decision-making.  This includes focusing on outcomes-based performance, rather than output-focused performance, and not just financial performance.


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