Published: 12 November 2018

Legislative Council Tuesday 30 October 2018

Ms  FORREST  (Murchison) - Mr President, I am happy to speak on this issue.  I am not going to reflect on what the Government Administration A subcommittee is looking at in its inquiry.  It will report in due course.  A few things being talked about in the public arena do need comment, particularly with my background in the health field as a nurse and midwife.  This is not reflecting on the work of the committee; this is reflecting on public comments I have made in other places and information already in the public arena.

I will touch briefly on a number of points already raised by members today - and not on some others raised.

Wherever I go, I constantly hear from health, legal and finance professionals and from everyday mums and dads who are users of the health service that we are a small state and that we need to work together to achieve the best health outcomes we can for the state.

We know Tasmania has some of the worst waiting times in the country.  As a result of having prolonged waiting times, you have worse outcomes.  We need to continue to focus our attention on the patient experience of accessing our health services and the health outcomes for the people using the service.  The money is important to this, but if we start talking about money and money only, we lose complete sight and vision of the patient experience.

We know people in this state are waiting extraordinarily and totally unacceptably long times to access necessary surgery.  They are also waiting extraordinarily long times to see specialists in outpatient clinics.  Some of these waiting times are hidden because they are not counted.  There are several points of waiting.  There is waiting to see your GP sometimes, which is not a state problem but a primary health - funded by the Commonwealth - problem, a problem I could talk for several hours on.  There is also waiting to get to see your specialist, and it can take many months just to receive your appointment.  When you have your appointment, there is another wait and you may need to visit the outpatient clinic to have pre-work done if you need surgery, and there is the wait for the surgery.  Maybe you are put off when you finally reach the point of surgery being imminent, sometimes by your own issues - perhaps because you forgot to fast or have a bad chest infection, which is a very good reason you should not proceed with the surgery - or a hospital issue like the surgeon is sick and cannot be replaced as it may be a specialist field or neurosurgery.

Mr Valentine - Or emergency surgery.

Ms  FORREST  - Yes, or it is a major case or you have comorbid conditions, common in Tasmania, or there is no bed in ICU - and bed block comes into this.  Everything is ready to go, the surgeon and the anaesthetist are available, the patient is fit and ready for surgery and the ICU is full, bad luck, cannot do it and you do not want to do it either because you need ICU after surgery.

There are lots of pressure points here and it is totally unacceptable patients are waiting so long.  As many people who look at the health economic and inpatient experience side say, we need to do much more and not just talk.

Another thing raised consistently - and I raised this in budget Estimates with the minister, who seems to be in some form of denial - is that we know the Health budget is a very money-hungry beast.  If you let it run out of control, it will take over the whole budget.  We have heard this for years.  Since I came into parliament, I have heard the same thing.  It takes 30 per cent of our budget and could consume 90 per cent if we let it, and we know we cannot have that.  Other states manage without doing that.

The minister keeps coming out with this completely stupid comment of record spending in health again.  If you do not spend more than you spent the last year, you are going more than backwards, because of CPI alone, and health inflation rises much more rapidly and is higher than normal inflation.  We all know this.  To say you spent more in health - if you had not, you would be rightly criticised.  The point is you should be criticised when your base funding is wrong.

Today the Tasmanian Health Service and DHHS annual reports were tabled.  They have been on the website for a week or two, although difficult to find initially.  I spoke to the minister's office and this was remedied because primarily it was not there when it was released.  It was tabled in another place a couple of weeks ago when they were here.  It is there now.

I will read some figures to illustrate why the minister is not being truthful about this.  In the annual report, the expense by Output 1.1, Admitted Services - that is, services provided in hospital once you are admitted, which is surgery and so on - in the 2018 budget was $819 545 000.  That was last year's budget. The actual spend - the actual expenses - for 2018 were $902 335 000.  Remember that figure.  We go to this year's budget for admitted services.  For this year, it is $879 435 000.  I haven't done the sums, but I think it is about $150 million to $160 million less than the actual expenditure last year.

It is not just this year this has happened - it happened last year, and the year before and the year before that.  We are not even budgeting for the amount we are spending.  In 2017 we had a nasty flu outbreak.  That was the reason and a legitimate explanation for some of the blowout of costs in the Health department.  I accept that.  This year we did not have a flu outbreak.  You could say, 'Thank God we didn't because what the hell would have happened then?' 

We had a massive supplementary appropriation bill last year to make up the shortfall.  The minister says they always fund the shortfall.  That is because they have no choice.

Surely the base funding should be in a position that can deal with extra demands, not just the flu or something like that?  There are fundamental problems here. 

For not admitted services, the budget in 2018 was $197 398 000.  The actual spend was $215 076 000.  The budget for this coming year is $189 880 000, less than the actual spend again.

For emergency departments, where there are enormous pressures right across the state, the budget for 2018 was $119 583 000, with the actual $150 817 000.  About $30 million extra was required to be spent.  The budget for this year is $120 214 000, $30 million less than we spent.

How are we ever going to catch up?  We are playing catch-up all the time.  I have been explaining this to people in the community using much simpler figures.  These are big numbers and it is a bit hard to comprehend.  Essentially we are budgeting for a figure, then spending significantly more and it is topped up from other funds, requests for additional funds - RAFs - or supplementary appropriation.  Then we budget less the next year, hoping it will be able to make do.  Every year we cannot make do - or we are not making do; whether we can or we cannot is another matter.

Mr President, it is there in black and white.  It is in the annual report; it is in the budget papers.  They do not lie; they are the numbers.  The minister is saying we are spending so much more.  Yes, we are spending so much more because you are not budgeting enough for it.  This is all on the public record in the annual report tabled today.

The other factor, which was looked at by a previous joint committee, is the area of preventive health.  We cannot consider this picture in isolation.  Preventive health is such an important aspect but it is underfunded and under-resourced, and that is more for the federal government than from the state.  You see national partnership payments being withdrawn or not continued.  The burden continues, with people accessing preventative health to keep them out of hospitals.  I strongly believe much of this is because of the cost shifting of Commonwealth funds to primary health.  If they end up in hospital, the state has to pay.  The state does not want them in there because then it costs the state.  They would rather them back out in the community, but we do not fund that, the Commonwealth does.  Surely we can work on this together?  We are not going to get anywhere if we do not.

We keep saying this.  I do not know if you listen to Dr Bastian Seidel, a general practitioner who was the president of the Royal Australian College of General Practitioners.  He is very intelligent and smart man, whose term as president recently ended.

Dr Seidel has presented to committees and spoken publicly to the media, and I am sure he has also been in communication with the minister.

We really should listen to people like him who are at the coalface and know.  He makes so many really sensible suggestions about dealing with this and the need to have a collaborative approach.

On the rural hospitals the member for McIntyre referred to, while their occupancy rates are low at times, they provide a really important part of the whole health system and there is a real need to better utilise them.

Ms Rattray - Do you mean by utilising them more, when people are let go from hospitals and are not ready to go home and that type of thing?

Ms  FORREST  - Yes and utilising them better like a step-down facility. Many reasons and excuses are sometimes given on why we do not do this - sometimes patients do not want to.  If they are holding up a bed in an acute facility and the care can be provided in a regional facility, perhaps we need to make some tough decisions sometimes.

Of course, it should be considered if they need support and care from their families who are not near the regional facility, but often they come from a nearby community.

There are many more opportunities to better utilise those.  I understand there are some barriers.  Let us look at overcoming the barriers and look at solutions, rather than saying it does not work.

Ms Rattray - A barrier may well be if you are reducing the staffing -

Ms  FORREST  - I will talk about that.  I have not actually seen the article you are referring to, but a bit of a 'turf war' goes on around this.  Assistants in nursing - that is what the term used to be; obviously it has changed to healthcare assistants - are people trained to undertake basic nursing duties.

As a nurse myself, there is always this fear they will impinge on the turf of the nurses and then move up the scale with nurse practitioners taking on a more expert role.  They have to undertake a master's degree and a range of other training in their field; they can prescribe medications within the field they are a nurse practitioner in.  They can order X-rays, blood tests and a range of other treatments.  They can suture and do a whole range of things.

This then became a turf war with the doctors because some doctors thought they were impinging on their area.  Notionally they were, but now, when you look at the nurse practitioners who work in the departments of emergency medicine, by and large, doctors think they are wonderful and fabulous because they deal with lower acuity patients - category 4 and 5 patients are seen and completely dealt with by the nurse practitioners.  That frees up specialist doctors to deal with the patients who need that level of care.  It is the same with the healthcare assistants or assistants in nursing, or whatever title they may be, so long as you have a good mix.  The member for McIntyre mentioned they were taking the registered nurses out of the place and putting these in place.  You cannot do that.  There are still nursing bed per patient day models that require a certain number of registered nurses.  Even if you have enrolled nurses, a patient ratio is determined.  I do not know the full details of that, but the Leader may be able to provide some information.

Mrs Hiscutt - Neither do I.

Ms  FORREST  - I do not see there is a problem necessarily with having other people undertake some of the nursing care roles to free up registered nurses to provide the higher level care, so long as you are not eroding it to the point where that registered nurse is trying to be all things to all people. 

Mrs Hiscutt - That is the point.

Ms  FORREST  - Yes.

Mr Gaffney - It is a bit like pharmacists being able to give injections and so on now.

Ms  FORREST  - That is right.

Mr Gaffney - That is a good thing.

Ms  FORREST  - Yes, they do vaccinations and flu shots.

Mr Gaffney - Some doctors initially were a bit wary of that.

Ms  FORREST  - Very against that, yes.

Mr Gaffney - That is improving.

Ms  FORREST  - Yes.  I have been through some of the turf wars, but it is a small state and we need to work together to get the best patient outcomes and experience, and not have people waiting extraordinary times.  So how do we move patients through the system in a timely but not overly timely manner? 

I will touch briefly on the comment the member for Rumney made about access to termination of pregnancies in public hospitals.  This is an ongoing disgrace from this Government.  Now they say they have a low-cost provider to be based in the south, but they will not reveal who it is because they want to protect women's privacy.  What a stupid excuse!  If you want to protect women's privacy, make it available in the public system so they can access it close to their home when they need it, and remove this secrecy that perpetuates the stigma and shame attached to a medical procedure that is legal and should be available in all our public hospitals.  It is an absolute disgrace.  It is shameful of the Government to continue to perpetuate this stigma and shame on women who need to access a health service.  It is just disgraceful.  I was rung by a journalist yesterday who asked whether, if the Labor Party gets in, they would bring in legislation.  I said, 'I don't care whether they get in or not.  They don't need legislation.  All that is required is for the minister to agree to put aside his personal philosophical ethical views on a women's health matter, put them aside, and ask, "What is in the best interest of women and health outcomes in this state?"'  All that has to happen is that the secretary can include it in the service delivery plan or the service level agreement of each of our public hospitals and it is done.  It is not fair, it is not equitable and it is not safe.  Now having a fortnightly service, we know that surgical terminations in this sort of clinic can only be carried out up to - I am not sure whether it is 12 or 14 weeks - but it is around that time.  You might miss one fortnight if you do not realise you are pregnant straightaway, which is quite likely if it is an unplanned and unwanted pregnancy, or if you do not realise you are pregnant and then realise that perhaps you are.  You might do a home pregnancy test, you might go to your GP and you then have to be referred.  The clinic for that day down here is full, so you have to wait a fortnight and then you are probably over the time limit and you will have to go to Melbourne anyway - 'If the clinic is on tomorrow, what am I going to do about the children?' 

A member - Can't get time off work.

Ms  FORREST  - Yes, 'What am I going to do with work?  Take a sick day perhaps but I have these other children I need to arrange care for.'  It is not that easy. 

Let us be reasonable here.  The minister needs to drop his philosophical opposition to this.  That is what it is.  He is making a moral judgment, not a health minister's judgment in the best interest of women.  I think it is unfortunate they require a termination because most of them do not want to have one, but they find themselves in a situation where that is the option they need to take and we should not be judging.  I think I have said enough on that.  I was not going to raise it but you did, so I thought I had to say something. 

I will not keep going much longer because other members may want to speak and there is a time limit on this MPI motion.  One of the other problems, in spite of the plan - and I commend the Government on some of its planning initiatives in trying to address some of these health challenges - is that the focus of the planning we are seeing is still way too short-term.  If you look at the Emergency Department at the Royal, when it was redeveloped two years ago, it was redeveloped to meet slightly more than the current demand even though the demand was projected to be much greater.  The actual demand has been even greater than what was projected.

We are playing catch-up all the time.  We need to be more visionary in this.  If the Government wants to pursue its policy of having 600 000 people by 2050 or whatever it is -

Mr Gaffney - It is 650 000 by 2050.

Ms  FORREST  - or 650 000 by 2050, we are going to have more people so of course there is going to be more demand.  You have to plan for that.  We will also get tourists using our public health system as well.  It is a universal access system.

Ms Rattray - They are the ones who come off their bikes.

Ms  FORREST  - Well, yes, or they get gastro on the boat and then rock up at the DEM.

Mr Gaffney - The member for Launceston raised the One Health System model compared to the three and the process we went through.  I would be interested to hear your comments.

Ms  FORREST  - I strongly believe we need the One Health System for our state, but we need to work together and maximise the potential of all of those centres.

Mr Gaffney - Yes.

Ms  FORREST  - If you divide, it becomes fighting with each other.

Mr Gaffney - Infighting.

Ms  FORREST  - Yes.  If you have one overall structure, we can, I hope, in my utopian world, all agree on what should be provided everywhere.  Not everything needs to be provided everywhere, such as particular surgeries, because a surgical intervention, ideally, is a one-off intervention.  If you need your hip replaced or you need cardiac surgery or an amputation - as the lady with the gangrene did, unfortunately - hopefully, once you have had the surgery, that is the end of that episode of care.

You do not necessarily need to provide particularly more complex surgery everywhere.  I think most Tasmanians would accept the need to travel for those sorts of things.  If they are going to be seen in a timely manner, it is going to be done, and then if they go home with support, that is fine.

For things like pain management - the member for Launceston has raised this a number of times and I have, many times - the lack of pain specialists in our regions is appalling.  If you expect a patient with severe chronic pain to get in the car in Smithton, Marrawah, Queenstown, Strahan or parts of the east coast, and drive to Hobart to see a pain specialist, they will need to see more than a pain specialist by the time they get there.  Then they have to get in the car and come back.  These sorts of things should be provided around the state.

I support the One Health System model.  There needs to be capacity for local decision-making on with local issues because each area has different issues, but you have to have a united approach to what services would be delivered where and how they are delivered.  Otherwise, you get this competition.

The members for McIntyre and Launceston raised the issue of spending money on Macquarie Point.  It is a separate issue.  We need to focus on health and getting the funding for health right.  Wherever it comes from, to me, is not the point.

I saw a letter to the editor a couple of days ago saying it was time to close the Mersey.  How many times do we hear this from people who live in Hobart?

The federal government gave us $735 million just over a year ago - or maybe two years ago now - for the purposes of running the Mersey for 10 years.  That money was then, except for the first $70-odd million, sent to TASCORP so it did not all appear on the Government's balance sheet in one hit because that would have made the outyears look really bad.  It was put in TASCORP so they could look after it and try to boost it a bit.  Allegedly we are getting 10 per cent returns on it, but I am not sure how they are going to do that.  That money is there for that purpose.  It cannot be used for anything else as I understand it.  We passed legislation to make sure it was not.  Perhaps the person who wrote that letter to the editor does not understand that.

The Mersey Hospital, if you look at the figures in the annual report, has an enormous throughput of patients - though not as enormous as that of the Royal or LGH.

Mr Gaffney - I went to the forum the other week. It was close to 30 000 presentations for a 12 month period. 

Ms  FORREST  - Where were they going to go?

Mr Gaffney - I do not know, exactly right.

Ms  FORREST  - This is the point of having one health system that works together to maximise each of our facilities in the best way possible. 

In an ideal world you would not have two major hospitals on the north-west coast but we have.  It is historical and somewhat hysterical.  When John Howard interfered and Tony Abbott was the federal health minister, it became difficult for the Labor government at the time.  The problem continues.  We have funding from the Commonwealth for at least the next nine years.  After that, I do not know if I will still be here to worry about it, but someone will be.  We need to address those comments in the media.  The minister should explain this to members of the public, particularly those in the north-west who see people suggesting the Mersey should be shut down and we would have $730 million to spend somewhere else. 

Mr Gaffney - To the minister's credit, when incorrect statements were made at the forum, he did address them.  I was pleased.  He said, 'No, that's not correct.' 

Ms  FORREST  - That is good.  They are the people in the region who need to hear that.  I was not there, so I do not know what he said.  We were in Hobart at a health committee. 

Much more will be said when the acute health services committee reports at a later time.  It is an important issue.  It will always be important. There are no easy solutions but we need to work together.  We need to acknowledge there is a problem, which I think the Government has done. 

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