Legislative Council Tuesday 27 November, 2018

Ms FORREST - Mr President, I will speak only briefly on this report.  As the member for Hobart said, the report speaks for itself and I encourage members to read it.  It contains a great deal of very relevant information.  I will speak to a few aspects of it.

I, too, thank the committee members and the committee secretariat, Jenny Mannering in particular and Gabrielle Woods for their hard work in putting this report together so we could table it by the end of this year and have time to debate it in this place.  It is important there is public debate around this issue.

As the member for Hobart alluded to, we could not recommence our committee deliberations following the prorogation of parliament before the last election until parliament resumed and we had a chance to put on notice the re-establishment, have a GAA committee meeting -

Mr Valentine - That was July, wasn't it?

Ms FORREST - Yes - have GAA approve the reappointment of the subcommittee and then start the subcommittee proceedings - that all takes time.  It was well into July before we could really get going and ask for updated submissions.  The committee has done an amazing job preparing such a detailed report in that short time since July when we called for updated submissions.  Here it is only November and we have a very comprehensive report.

The reason it is a second interim report and not a final report is because we have not had a number of outstanding or delayed responses from the minister.  We tried to get the minister before the committee in time to include his input into the committee report on this occasion, but we were unable to do so.  There were times when he did not respond in a timely manner to our requests, so by the time we got him to appear before us, we had basically signed off the report.  That is why we are here today debating a second interim report that is lacking some detail in some areas.

The executive summary provides a clear overview about the demand and the challenges faced by the Tasmanian Health Service.  No-one says providing health services is easy anywhere.  All states are facing challenges, but it is very clear that demand for health services in Tasmania is growing more quickly than people expected - people being government officials, the Health department, the minister, Treasury - who have to approve funding for health - and Treasury officials.  They underestimated the growth we are going to see.

We all expect and acknowledge there are times when we have unusual episodes of growth related to a particular event; 18 months ago it was a major flu season.  Those things happen.  This year we did not have that, but we still saw the same level of growth.  It is not just a one-off event; it is a continuation of the demand for health services in this state.  To say that we top up funding to meet these extraordinary events - because that is what it was - for the year before you could argue that, with the flu season, but not this year and I imagine not this year we are in.  The minister has recognised that to a degree because in the paper today he was talking about throwing another $100 million-plus at Health, but without any real clear plan about how that will fix the problem.

The demand is increasing and hospital overcrowding has become the norm.  That is not okay.  The evidence in this report and in other sources from which we had information is that hospital overcrowding is creating adverse patient outcomes.  The idea of providing a health service to Tasmanians is that they do not have adverse patient outcomes; they go in and have whatever they require, get better and leave.  We are seeing avoidable mortalities occurring in our hospitals.  While some may dispute the validity of the collection of this data, data released by the Grattan Institute very recently shows that Tasmania is the only jurisdiction where the unavoidable mortality rate is increasing.  In Western Australia it is static; in all other states it is reducing.

Regardless of whether that data is totally accurate in terms of how you measure the avoidable mortality, these are people dying who should not.  These are people who should go home, but they are dead, and that is not okay.  I am not saying we are going to avoid every potentially avoidable mortality in our hospitals, but if they are avoidable, we should be able to.  Some people are going in and they are going to die because that is where they are at.  We are not talking about those people.  These are people who were not expected to die but they did, in our hospitals.  Coroners' reports have shown that to be the case.

It is not something we can just brush under the carpet and say we do not agree with those figures.  This is happening, so let us fix it.  As Dr Duckett said when he spoke to us - he works for the Grattan Institute and took leave of absence from the Grattan Institute to undertake the review of the circumstances surrounding the deaths of a number of babies in a Bacchus Marsh, Victoria hospital.  He then made a number of recommendations, out of which flowed the Safer Care Victoria model.  That is mentioned in our report if members are interested in looking it up. 

In his evidence to us, he said -

I try to avoid focusing on how much you are spending.  I would rather focus on what the experience of the patient is. 

That is a really good idea to focus on the experience of the patient, because it should be patient-centred care that we are providing in a hospital.  He goes on -

The experience of the patient is that they are waiting far too long, and that they are sicker than they ought to be.  Then what I say is, 'This is what we can actually see.  I do not actually care whether you think you are putting in enough money, or you are not putting in enough money, the outcomes are not good enough for Tasmanians, and it is your job to fix it'.

That is his message to the minister.  It is clear when you look at the information on pages 97 and 98 that Tasmania is experiencing a higher level of avoidable mortalities than we should be.  Those are people who are dead, and they should not be.  Probably they would not be dead had they not have gone to our hospitals.  That is what that means.

They might have died some time later of something else, but they should not be dying in our hospitals - and they are.  That is not okay.  It is not okay by me.  I am sure it not okay by you. 

We talk about the funding of hospitals and the historic underfunding.  This is not just the fault of this Government; it has been going on for years.  It goes back before this Government came into power.  But for the minister to come in and say that we are spending record funding on health and put out all these media releases on 'record funding on health' - of course you are, every year, because demand increases, and not only does demand increase, but we know that health inflation costs are higher than general inflation.

If you are not putting more in each year, you are actually going backwards by a large degree.  Of course it is record funding each year.  That is a nonsense to use that as an argument.  It is like saying that a 6 per cent pay rise over three years is more than a 2 per cent per annum rise.  He needs to go back to primary school and understand how you add up if that is what he thinks.

Mr President, we have to be truthful with people in Tasmania.  That is what they want.  They want to hear the truth, and they want to understand what we are doing to address these very real challenges.  When you look at the funding in health, there is a table on page 83 compiled from data from the Tasmanian Health Service annual reports, the Health department's own reports, and the Government's own budget papers.  This table clearly shows that every year in two areas that particularly relate to the acute health services - admitted services and emergency department services - we are spending significantly more than what is budgeted.  The chart shows back to 2015.  It is a little bit hard to go back before that because we had a different structure with Tasmanian health organisations then.  But it has still been a problem back then.  Even so, I do not think it was quite to the same degree.  However, let us look at it while this Government has been in power:  in 2016, the budget was $760 million plus a bit; the actual was $788 million plus a bit.  In 2017, the budget was $772 million plus, and the actual was $835 million plus.  This past year, 2018 just gone, the budget was $819.5 million - so $819 million - the actual was $902 million and a bit extra. 

We approve supplementary appropriation bills, we approve RAFs - requests for additional funding - to top up the Health budget.  This tells me there is an underlying problem if we have to top it up every year.  In the 2017 budget year, you could argue some of that related to the flu season.  True, but in 2018, it does not.  That year was even more.  Even more we had to top it up. 

There is a chronical underfunding issue here.  Just to throw another $100 million plus at it without a real structural plan for that will not necessarily fix the problem.  As identified in the report, one of the problems is patient flow; we are not getting patients out the door of the emergency department or out the door of the hospital when they are in the wards, or out the door of the emergency department and into a ward because they are not leaving the hospital wards.  So, the whole patient flow challenge is very real. 

As the member for Hobart said, one of the biggest constraints at the Royal is the physical infrastructure.  We know that to be the case with the Royal rebuild, and, yes, it has been an ongoing battle and challenge, but it is not confined to the Royal.  We are seeing the same sort of challenges at the LGH and more recently in the last few months I am hearing about the same thing happening at the North West Regional Hospital in Burnie.  Patients are being sent home because there are no beds.  Patients are waiting way too long in the emergency department and patients with mental health conditions are being sent home because there is no appropriate care.

Young patients with mental health issues actually have nowhere to go.  A young patient I am aware of ended up in ICU because there was nowhere for her to go.  Eventually she was sent to the children's ward, not an ideal location for a 17-year-old with acute mental health issues - not suitable but nowhere else to go.

How long have we heard we are getting adolescent mental health beds?  We heard it from the last government; we heard it from them and it did not happen.  We have heard it from this Government for five years now; they say it is going to happen.  I will be celebrating when it does because this is a really sad thing to try to help a family, help some parents who really care about their child, who cannot get access to acute mental health care when their child is suicidal.  It is not okay at all.

We know that mental health patients particularly are spending too long in emergency departments.  It is a really sub-therapeutic environment.  Acute mentally unwell patients need a quiet environment.  They do not need all the stimulation; they do not need bright lights.  They do not need people rushing around; they do not need alarms going off all the time and they do not need a code black happening every few hours to re-enliven their senses.  They do not need that but that is what they are getting; that is where they are.  Patients are being treated with invasive procedures in corridors.

Mr Valentine - They need a different access point.

Ms FORREST - That is another matter that should be explored, the access for acutely unwell mental health patients so they do not come into that area.  They are dealt with separately.  There are also equity issues there and often those mental health patients may also have physical health conditions that need to be accessed.  They do need to be cared for in a place that is therapeutic, ideally not in the emergency department for more than a few hours, two, three or four hours, but into a more appropriate therapeutic space.  They do need that particular different level of care than you can provide easily in an emergency department. 

As the member for Hobart mentioned, there are a lot of findings in this report.  I urge members:  if you do not read the whole report, at least to read the findings.  All the evidence is there in the report if they are thinking how did they come to that?  It is there.  The patients who spoke to us about some of their experiences - it was hard because we knew their experience was very valid and very real and we could not actually assist them.  That was not the job of the inquiry but it also became very apparent that the Health Complaints Commissioner is severely under-resourced.  They have had their funding cut and their FTE staffed reduced making it even more impossible.

We are talking about the Ombudsman generally; this sits within the Ombudsman's Office.  I know the member for McIntyre raised this as well.  We recently passed some legislation to give the Health Complaints Commissioner a whole heap of extra work and quite extensive powers in relation to unregistered health practitioners, including the power to deregister a person.  One of my main concerns at that point was:  is this being resourced? 

We asked Mr Connock about it and how he dealt with this legislation that passed to give him a bit more work, and the report states on page 127 -

When questioned about the additional workload related to codes for conduct for an unregistered practitioners Mr Connock stated,

'We are horrified'.

What is the Government doing to assist them?  We cannot continue to throw more really important work at these departments.  If someone is sexually abused by a massage therapist, they will probably also make a common law claim, but a complaint could come through this body.  He went on to say -

I have been in contact with my counterparts interstate, New South Wales, South Australia and Queensland already have codes.  I have been speaking to them about the impact on their offices of that.  I have been to see the Secretary of the Department of Health and Human Services and I have been to see the Attorney-General.  They are aware this is potentially a difficulty.  We do not know how big it is going to be down here, that is the problem.

Ms Whyte, the Health Complaints Commissioner within the Ombudsman's Office, added -

There is no question we are going to have to bring a lot more rigour to the investigation based on the fact it has the potential to impact on someone's employment.

The Office of the Health Complaints Commissioner is absolutely under-resourced.  We already know about the delays in assessing complaints through the Ombudsman's Office.  The Government has to do something.  This is a statutory office that needs to be properly resourced.

That concludes other matters incidental thereto, but we felt it had such importance, it needed to be included in this report.  The other thing is, there is no one port of call for complaints, so people are encouraged to go back to their healthcare provider, which is not unreasonable.  They then become shunted around.  A suggestion was made that should not be the case.

I encourage the Government to respond.  I know it cannot respond today directly to all the recommendations; it will in due course.  We really need to look at how we manage these matters.  How we manage the flow of patients.  How we improve the efficiency within our hospitals.  It is not about cutting nursing staff.  It is like trying to play a string quartet with two players.  You cannot do it.  It is a service delivery model.  Nurses can only look after so many patients at a time.  You need specialist placements in some areas, particularly ICU and the emergency department, and the nurse-to-patient ratio there is different, as it should be.  Those people are very sick and require much more intensive and targeted care.

We need to be looking at this budget shortfall and not topping it up all the time.  There are always times when you cannot budget exactly.  I am not saying the Government should be budgeting exactly what it is going to need.  There will always be times when you may need a bit more, but when you are consistently - every year - paying $150 million to $160 million additionally, something is not right.

We need to spend more in the preventive health space to make sure we keep people out of hospital in the first place.  When the minister presented to us, he was talking about how fantastic the Government was doing in reducing the waiting times and how it had them down to a bit over 5000 people, still a lot of people - that is across all categories.  The committee looked at the latest data on the Government's health statistics page.  It is true that in July 2017 the total number of patients on the waiting list across all categories was 5403.  By June 2018, it was 7933, back to where it was before.  I pointed this out - it was on the minister's own website.  He knew about it, but he chose to say, 'Look at what we did last year'.

This is the real thing.  This is where we are now.  These are people waiting too long - not all of them, but many of them are waiting too long for the surgery they need.  This is on page 23, and there is further information about patients who are waiting too long.

All this data is in the report, and some of it has been provided by people who put in submissions, like Dr Martyn Goddard and others.  Much was taken directly from the Government website or the Australian Institute of Health and Welfare to be sure our data in here is correct - all from the Government's documents - like the annual reports of the Tasmanian Health Service, and others.

Those are the points that I wanted to make.  There are some very big challenges for the Government.  There are some very big challenges for the Health Service generally.  No-one is saying it is easy. 

We are still waiting on information.  One of the points of information we are waiting on is the review that we were informed of about this time in 2017, of the North West Integrated Maternity Services.  There have been a lot of concerns about the lack of continuity of care, the problems for midwives and operating costs, their full scope of practice, staff and potentially women's dissatisfaction with the service - not with the care when they get it; it is the continuity of care and the midwives being able to operate across their full scope.

We asked for a copy of this report some time ago in October but we still do not have it.  Again, we cannot complete that section of our report because we want to know what is happening with that.  The staff were promised a review; we were told it was imminent in November-December 2017 and we still do not have a copy or any information on what the review found.  I am very concerned about that because it is an area that is very close to my heart - North West Maternity Services.  We had a fabulous service up there.  The midwives who work there still provide very good care for the women they care for, but the job satisfaction is going down the drain because when you cannot work across your full scope of practice, one, you risk being challenged when you are re-registered if you are audited by AHPRA, and two, there is no job satisfaction.  Midwives will get burnt out and leave, and then you have the problem of recruiting new ones.  Specialist fields are not easy to recruit.

These are the key points I wanted to make.  There is a lot more in there but we will be presenting a final report once we get this information we are seeking.  I am not going to comment on the KPMG report that the member for Hobart mentioned; that is a matter for another day. 

Mr President, this report needs to be taken seriously by the Government.  I am sure that the minister has had time in the interim to read it.  If he has not, I am sure his adviser has.  I am sure we will get a more comprehensive response in due course, but we did want to report while this information was relevant.  I sincerely thank our secretariat for completing such a body of work between the end of July and now.