Legislative Council, Tuesday 15 November 2022

Ms FORREST (Murchison) - Mr President, it is my pleasure to speak to this report and I particularly thank all those who provided evidence by way of written submissions and verbal evidence to the committee. Their valuable insights and varied experiences within health care in rural and regional Tasmania and beyond has informed the committee's work.

Many who contributed are very busy doing the best they can in very challenging circumstances to deliver quality health care to those Tasmanians living in rural and regional areas. I thank them for their contributions and hope that we have captured the key messages and provided some clarity about the very real challenges and inequity experienced by Tasmanians living in rural and regional areas and those who provide health care to them.

On behalf of the committee, I also acknowledge the dedication and hard work of all our health professionals who go above and beyond to deliver the best health care they can. I know and understand their deep frustration when working in situations of workforce shortages and increasing demand.

These workforce shortages are compounded in rural and regional Tasmania by a range of factors including a maldistribution across the state, the capacity to cover periods of leave, ill health and professional development. Some of those things they actually miss out on because they simply cannot get the coverage to enable them to participate in professional development, for example. This makes it extremely difficult because you are required to do a certain amount of continuous professional development to maintain your registration under the Australian Health Practitioner Regulation Agency (APHRA).

I sincerely thank all our health workforce members for their ongoing dedication and commitment to the health and wellbeing of Tasmanians in the face of so many challenges, particularly those who live and work and care for people in our rural and regional areas. In addition, the significant impact of the COVID-19 pandemic on the health workforce and delivery of health services has been exhausting. This includes impacts on the provision of timely health care in both the primary and acute health care settings. These challenges have been compounded by workforce shortages, some related to COVID-19 isolation requirements and the temporary suspension of non-urgent surgeries.

This inquiry is the first conducted by a Tasmanian parliamentary committee into rural and regional health services. There have been a number of previous inquiries into acute health services and into preventive health, which I have also participated in, but this is the first that was dedicated entirely to looking at rural and regional health in Tasmania.

Health and health care are areas where there are more acronyms and abbreviations used than in almost any other. For those outside the profession understanding these and the various roles of a range of health professionals and practitioners can be quite daunting. For this reason, the committee attached an appendix, Appendix A, which contains definitions and a glossary related to the health-related terminology and a description of the roles of health professionals referred to throughout the report. I hope members and others will find that helpful when reading the report. This is in addition to the usual page of abbreviations. In this report, that alone runs to four pages, all there to help the reader.

In this inquiry, the focus was on health outcomes of Tasmanians living in rural and regional areas and the barriers to, and opportunities to improve, access to health care and thus improve their health outcomes. Whilst not a surprise to many of us, this type of inquiry has confirmed a number of concerning realities regarding access to health services and health outcomes for individuals and families living in rural and regional areas of Tasmania.

Tasmanians experience poorer health outcomes than those living in most other regions of Australia. Furthermore, when compared to Tasmanians living in urban areas, those living in rural and remote areas are older, sicker, poorer and experience more negative health outcomes related to the social determinants of health. I will let that sink in a little bit because that is a really important point: Tasmanians living in rural and regional areas are far worse off in relation to their health outcomes than Tasmanians living in Hobart and Launceston, for example.

These social determinants of health include factors of low socio-economic circumstances, higher rates of smoking, obesity, poor nutrition, low physical activity levels and chronic disease. They have longer wait times and limited access to many health care services including allied health professionals and Tasmanians living in rural and regional areas have less access to multi disciplinary care. They have higher rates of disability and poorer mental health outcomes. These factors in addition to the geographic isolation result in the greater need to access a range of health services - many of which are not locally available.

Tasmanians living in rural and regional Tasmania also have poorer health outcomes, particularly with regard to mental health and these poorer outcomes are exacerbated for some groups, including the members of the LGBTIQA+ community.

I draw members' attention to finding number 8. This finding notes that barriers to access of health care in rural and regional Tasmania are multifaceted and relate to a range of matters including:

• a higher percentage of residents living in low socioeconomic circumstances and poverty;
• lower levels of literacy, including health and digital literacy;
• the high cost of health services; transport to access services and digital technology and access;
• the geographic distance to metropolitan health services;
• a lack of suitable housing for health professionals in rural and remote areas;
• inadequate access to high-speed internet and lack of access to modern digital infrastructure and associated technology in rural health facilities;
• a lack of community awareness of all available allied health services and programs;
• the stigma experienced by people, including sex workers, LGBTIQA+ Tasmanians, culturally and linguistically-diverse Tasmanians and those with mental health conditions, intellectual disability and dementia;
• the lack of dedicated and inclusive services to meet the specific needs of women, including sexual and reproductive health care and pregnancy termination services and the needs of the LGBTIQA+ Tasmanians; and also
• the inability to self-refer for mental health services.
These are just some of the additional challenges that people in rural and regional Tasmania face and our findings and recommendations revolve around these very real and lived realities.

It is vital these very real barriers that those living in our urban areas may not appreciate or ever experience, are understood by all of us and the policy and decision-makers.

As many of the matters raised with the committee crossed over a number of terms of reference, the findings and recommendations of the committee were consolidated and relate to the need for direct action to address all areas raised with the committee and thus, there are not findings or recommendations related to each particular term of reference or subsection of a term of reference, but rather consolidated to give a comprehensive and fairly succinct set of findings and recommendations for the Government to consider.

The evidence received identified the clear links between lack of access to health care and poorer health outcomes. If you cannot get access to health care, your outcomes are going to be worse. It seems like a no-brainer but we seem to continue to overlook that fact. These poorer health outcomes are further exacerbated in marginal groups of people within rural and regional areas, including members of the LGBTIQA+ community.

Our recommendations are inclusive of all Tasmanians living in rural and regional areas. I note actions taken to address inequities need to include additional supports to groups of people at increased risk within these communities.

As noted in the report, the poorer health outcomes of those living in rural and regional Tasmania are linked to multiple issues of access-related barriers across a number of underlying factors. These factors include:

• a high percentage of residents living in lower socio-economic circumstances and poverty. We know the data clearly shows that people living in rural and regional Tasmania have a higher percentage of people living in low socio-economic circumstance.

• lower levels of literacy - we continue to see that as a problem which includes health literacy and digital literacy. If these things are not addressed then you cannot access even digital health if people are not digitally literate.

• the high costs associated with access to health care and stigma experienced by marginalised Tasmanians.

As a result of the barriers experienced in accessing timely health care, Tasmanians living in rural and regional areas often delay seeking care and have more complex health care needs when they do seek care.

We heard a lot about this, not just in Tasmania. This also occurs in other remote and rural areas in Australia. If people cannot get access to their health care promptly, they put it off and put it off until they are really sick. Then often they will either be very complicated when they see their health professionals, whether it is the doctor or another allied health professional, when they are much worse than they would have been if they had had access to early care.

When that happens, they have more complex health care needs when they do finally get to see a health professional. This then requires longer consultations with what might have been dealt with when a standard consultation no longer can be - it requires a longer consultation and nearly always more follow up care that our current Medicare benefits schedule does not adequately financially support. That is a matter we spoke a lot about in the report but I will come back to that.

This is particularly important as almost 50 per cent of rural or regionally based Tasmanian adults have three or more chronic health conditions, all of which will take some time to manage and monitor. Referring back to the preventative health committee, if you do not intervene early and manage chronic health conditions well, they escalate and the person becomes sicker and ends up in the acute health system.

I have said this for some time now and when the media asked me about it, I reiterated it: the way to fix and address acute health service workload, ambulance ramping, bed block and all that is to prevent people going to hospital in the first place; the way to prevent people going to hospital in the first place is to keep them well in the community. The way to keep them well in the community is to ensure that they have access to health care in a timely manner.

That is not just the GP. The GP plays an important role. It is a range of other health care providers that mean that person can be cared for outside the hospital system; otherwise, they end up back in the hospital system again. They are often sicker when they get there, they end up staying longer in the hospital, taking up a bed longer and the problem goes on in the acute service. They keep throwing buckets of money at acute health services, but what do we throw at primary health? Less than 5 per cent of our budget.

If we can deal with this, over time we would see a reduction in pressure on these acute health services. However, no government is willing to bite the bullet - this is federal as well state - to fully invest in the front end because it takes time to see the result, many years in some cases.

The interactions between the conditions and medications that may be needed to treat these people with the chronic conditions, noting that almost 50 per cent of people living in rural and regional Tasmania have three or more chronic health conditions, also adds time to their care to ensure a patient is getting the best possible care.

The Medicare benefit schedule does not recognise this additional burden which is much greater in the rural and regional areas. The Medicare benefit schedule is the same, whether you are in an urban practice or a rural practice and it clearly does not work that way.

It is noted in the report that unless specific action is taken, health outcomes, including mental health outcomes for Tasmanians living in rural and regional areas, are likely to keep getting worse. It is already worse than everybody else. It will get even worse. Are we happy to accept that? I hope none of us is and I hope the Government certainly is not.

I am sure all of us in this place fully appreciate the need of a trauma informed approach to care in all areas. The committee received evidence related to this matter and particularly with regard to the provision of mental health care. It is also important for us to raise community awareness of the importance of trauma informed care, as well as encouraging the delivery of trauma informed services. Both aspects are integral to improving health outcomes for all Tasmanians.

A key finding of related recommendations relates to the availability of integrated and multi disciplinary health care services. Integrated and multi disciplinary health care services are important parts of overcoming access barriers. These services require an approach that is informed by local community needs. We heard in our debate earlier today with the men's sheds, every community is different.

Every community has different needs and if you want to look at how to structure health services in a community, you have to look at the community, and talk to the community. You have to see what the community needs. You cannot assume what will work in one part of Tasmania, particularly an urban setting, will be the same as what is needed in a rural or regional part of Tasmania. It most likely is not, and you may have services that are underutilised, and then massive gaps in the areas that actually need care.

Local community needs also include the needs of cohorts within any particular community. We all know that the healthcare needs on King and Flinders islands, for example, will be different than the needs in the west coast or east coast communities. We know, on King Island for example, people are generally better off. Everyone is pretty much employed with two or three jobs; generally, that comes with better education access. They are not living in poverty and so, their health care needs will be different than the general west coast community, where we do not see that.

The decision as to what integrated and multi-healthcare services are put into a community, or included in a community, requires an approach that is informed by local community needs, and local community engagement that is focused on the community and led by the community. Individuals and groups within those communities that are culturally and linguistically diverse, or members of the LGBTIQA+ community, or those who have experience of a disability and so on, will often have additional challenges in seeking and accessing health care. On top of the community consultation and engagement in terms of what services need to be where, you also need to dig a bit deeper into some of the specific needs within a community.

These groups of communities within a community also need to be included in the determination of what a community-centred approach will look like. To address the inequity in health outcomes for Tasmanians living in rural and remote areas, the committee found a holistic, intergenerational wellbeing approach to the delivery of health services is essential. When you have intergenerational factors, that is when you need to talk about taking an intergenerational approach. You have intergenerational poverty, intergenerational family smoking and, perhaps, other unhealthy activities that, unless we directly -

Mr Willie - Intergenerational poor educational attainment.

Ms FORREST - Yes, poor education attainment and lack of engagement with education generally. All of those things will have a negative impact on the health outcomes of that community. Unless you look at some of those intergenerational factors, you will not necessarily fully address them. For those with an interest in understanding more fully the extent of the challenge in ensuring all Tasmanians have equity of access to quality health care and similar health outcomes, I and the committee encourage further reading of the submissions and transcripts of evidence that are contained in the report. The rest of them are all published on the committee website.

The committee heard significant evidence of barriers to access of timely care throughout rural and regional Tasmania. The overarching themes related to these barriers include workforce shortages and recruitment challenges - and I keep hearing from around my community, and I am sure it is the same in other rural and regional areas, about the number of unfilled positions in some of these areas in our health workforce. I am not suggesting it is easy, by any stretch, at the moment; there is a lot of demand. However, you have to look at why that is, what are the underlying factors that are contributing to our workforce shortage? The inability of some health professionals to work across the full scope of practice for which they are qualified. This is the beauty of having a committee of inquiry, because some of these things sharpen the focus of the government of the day and they address some of these things. For example, we saw legislation brought into this place during the year to basically remove any restrictions for paramedics to enable them to work in settings outside of Ambulance Tasmania; and we are seeing a slightly greater focus on nurse practitioners and expanding their role.

There was a recent announcement around dealing with the massive outpatient clinic waiting list and extraordinarily long waiting times by using nurse led clinics. Some things do, perhaps, resonate. Some will say they were happening anyway; maybe they were, maybe they were not - but certainly, it helps to focus the attention.

One of the other themes included the inability of some health professionals to work across the full scope of practice for which they are qualified. This is an ongoing challenge, to ensure that we fully utilise the health workforce we have. If you have health professionals who are qualified and able to work in an area where they are perhaps limited because of some other barrier, then we are not doing the best we can. There are mechanisms and back stories to all of that that need to be addressed. Some of them are a federal government responsibility, some of them are state; but we need to make sure that we remove any of those barriers that falsely prevent health professionals across the whole gamut of health professions to work fully across their scope of practice. I am not suggesting for a second here, and nor did the committee, that we encourage people to work outside of their scope of practice. That is not what we are saying. What we heard was that were there were limitations on a number of health professionals to work across the full scope for which they were qualified.

Particularly in rural and regional Tasmania, there is a lack of integrated, community centred, multidisciplinary care. The previous comment I made feeds straight into this. If you are going to fully utilise your health workforce and you do it in a multidisciplinary community centred centre, you will get better health outcomes and more access to care because it will be targeted to the needs of the particular community - which varies around the state and you will have a range of health services there. You are then not just using your GP to do things that a GP can do, because they are qualified to do a lot, but there are other people in the health professions that can do some of that care. You use the skills you have to free up those to maximise their capacity to work to the top of their scope and across their full scope as well.

We also heard of inflexible funding and employment arrangements, which make it difficult for some of our doctors - particularly GPs - to work across a range of areas, like working in a hospital in the ED, as a rural generalist, but also working in private practice. There were some barriers that are described in the report around that.

As you will see in the recommendations, a lot of this requires collaborative work between the state and federal governments to address them. It is not just a state government problem. When we started looking at rural and regional health, we knew that much of it is the responsibility of the federal government.

As noted in the report, a one-size-fits-all approach will not meet the health needs of rural and regional communities, nor will it enhance the recruitment and retention of health practitioners to rural and regional Tasmania. Whilst not a new problem, and perhaps one that is exacerbated by the COVID-19 pandemic, high staff turnovers and a reliance on locums to deliver health services in rural and regional areas limit access to continuity of care and the positive health outcomes associated with continuity and timely access to care.

We constantly hear, and I am sure any member in a rural electorate will understand, that people find it very difficult to have to tell their health story - which can be quite complicated time and time again to each new locum who turns up. That is when mistakes are made. That is when medications are changed without, necessarily, full consideration of all the other factors that a GP who has provided continuity of care would have understood of that person. They probably understand their social circumstance, they may understand their other family challenges, because they are part of that community. You do not get that with locums. Whilst locums form a very important part of our health service, they should not be relied upon. They should be a stopgap, or a fill in, if you like, for allowing that health professional to undergo professional development or take a break, like annual leave. There should not be a revolving door of locums. If that is occurring, we are not delivering the best health care we can over a period of time.

The findings in this report clearly articulate the underlying challenges that contribute to poorer health outcomes. I note the Government and Department of Health have been working to deliver some alternative and innovative models of care with some success, particularly in the mental health space; and the committee did acknowledge that. For example, this includes the Police Ambulance Clinician Emergency Response (PACER) service, which has been implemented in southern Tasmania to support people experiencing mental ill health, with a community-based response to avoid acute care admission. That is a really positive thing. The last place a person with a sub-acute or acute mental health experience needs to be is in an emergency department of a major hospital. It is the absolute worse place for them. This has been a really effective model and due to the success of PACER, it is now being expanded statewide, first up in the north-west and then going to the north at some later time. The Leader may refer more to that.

This success reinforces the need for innovation across a broad range of health care services. These types of health care delivery models need to be considered across all areas of health care, and how we could do things differently is really important. In all areas of our care, how do we promote hospital avoidance and improve patient outcomes at the same time? For most people, hospital is not the right place for them. However, for some, that is where they end up because of lack of other opportunity and services.

There is a growing recognition that the capacity for health professionals to work across their full scope of practice is crucial to effective delivery of health services particularly in rural and regional areas.

Failure to facilitate this results in the lack of full utilisation and deployment of the human resources and skills available to meet community needs. I think this is changing. In the past we have had professional turf wars. Everyone understands what professional turf wars are and look like and these have limited the full utilisation of the skills a range of health professionals have. Thankfully we are seeing a reduction of this resistance because people have seen the benefits of working together across available resources and we know when we do that, we do get a better outcome.

Having pharmacists in GP surgeries. Having pharmacists in emergency departments to prevent medication errors in the acute sector. Enabling pharmacists to do more in their practices with vaccination and other care. However, where they are providing some of that care, pharmacists do not get renumerated for it and that is a problem. It is a federal government matter, but it adds to the whole picture.

I do think the professional turf war is reducing. Everyone is seeing that if we do not all work together, we are not going to make any difference to the very real challenges we face.

Professionals including paramedics, nurses and nurse practitioners, pharmacists and allied health professionals have a vast range of knowledge and skills that can complement and not compete with medical care or each other. Working together will create better health outcomes and will lead to a much better utilisation of what are pretty scarce human resources.

The committee found nurse practitioner and paramedic practitioner workforces are not as broadly utilised in Tasmania as in some other jurisdictions. There has been much more work done in other parts. We even talked to people in New Zealand about their use of nurse practitioners, which is more advanced than ours. It would be wise to look at other states and other jurisdictions, like New Zealand where they have actually progressed this much more quickly than we have.

I believe an expansion of these roles should be progressed to support the health workforce, particularly in rural and regional Tasmania. The report provides significant evidence of these matters and describes models where broadly utilisation of all available health care professionals, across a whole scope of practice, reduces workload pressures and can improve timely access to care and thus patient outcomes.

The expansion of pathways for general practitioners, such as rural generalist, are recognised as vital to health and wellbeing of Tasmanians in rural and regional Tasmania.

We need to remember and remind ourselves that general practitioners are specialists. People talk about getting a referral to your specialist from your GP. Your GP is a specialist. Rural generalists who are GPs who also have another level of a qualification on top of their general practice qualification can also hold their own in an emergency department. They have emergency department skills as well general practice skills. General practitioners deal with everything that walks in the door. They do it in a place where they do not have back-up to the same degree a person in the emergency department has. They are having to make decisions about whoever person presents to them with whatever condition they have. If that person is unable to communicate very well; they have to try to figure out what could be underlying that.

I recently went to the Rural Health conference and to a session about rural generalism and the role in emergency departments. They did a few case scenarios. Imagine what came back to me? We were working in pairs and I was working with a wonderful GP from a very rural and regional practice. We discussed these case scenarios that were put to us and it reminded me how difficult it is when you have limited facts: you have a person who fronts up with what might appear to be not a huge range of obvious issues and you are trying to find out what is wrong with this person. They are obviously not well, but what could it be?

We are often quick to criticise health professionals when they do not get it right the first time. Where you can have someone present with apparently normal, say, an ECG that subsequently changes and you have looked at the first one and not the second one until perhaps a little bit later and things have happened in the interim; we need to cut health practitioners a bit of slack sometimes and work with them.

It is really important to recognise the very important contribution general practitioners make to our community and the expansion into rural generalism is a positive thing for this state. It has a while to get there. This training is based at the Mersey Community Hospital and it will be a really valuable part of our response to this. Rural generalism has demonstrated benefits related to the delivery of timely and accessible health care in many parts of Australia in rural and regional areas.

The Rural Generalist program initiated at the Mersey Community Hospital is still relatively new, but a really important aspect of improving rural and regional medical workforce issues. I commend the Government for their work on this and encourage ongoing support and expansion, that is both federal and state.

It is of particular note that other professionals, including nurse practitioners, paramedics, pharmacists and other allied health professionals faced limitations on the full utilisation of their skills within the health workforce.

It is important to remember that paramedics are the only health professional who are trained to work in the community. Nurses are trained to work in hospitals. They may go there to work as a community nurse, for example, but paramedics are trained not to work in hospitals but to work in the community. Yes, they have an ambulance to back them up with a lot of equipment but they are trained to work in the community. They are also professionals who turn up to whatever they are called to not knowing exactly what they will have when they arrive. Sometimes, the description of the person who has made the call may be less than helpful but at least they have called them.

The full utilisation of the available workforce is particularly important and this needs to be fully progressed by the government - both state and federal.

The committee, through this report and the evidence that sits behind it, urges the state Government to identify and remove any other barriers relating to legislative limitations, employment arrangements and education and training across identified areas of workforce shortage. You will see in the report there is quite a list of workforce shortage areas. You can just about choose any of them.

Mr President, this includes real and serious consideration of policies - such as was recently announced by the Victorian Government to fund the Higher Education Contribution Scheme or HECS costs of nursing and midwifery undergraduate students and to provide scholarships for postgraduate studies in areas of need, including intensive care, cancer care, paediatrics and nurse practitioner specialties. That is in Victoria, and the committee recommended the state Government considers such an approach, particularly where we have really large areas of identified need and particularly, because we know that graduates in health particularly nurses and nurse practitioners and others who we educate and train in the state - if they are educated and trained in Tasmania, they are more likely to remain and work within the Tasmanian health service post graduation, provided we pay them a commensurate wage. There is that.

As a committee, we agreed a similar approach to support the training and education of health professionals in other areas of identified work shortages, including nurse practitioners, paramedics and allied health professionals should also be considered for subsidised education and training. We heard time after time that we cannot get occupational therapists and the importance of occupational therapists. We cannot get social workers and the importance of social workers, and others like physiotherapists. Some of them are not trained currently in the state, but UTAS has actually introduced some allied health programs into their offerings now, which is great. Where there are real areas of shortage, let us talk about it. How do we make it easier for people to get into these?

There are probably some really great people who would love to work in those areas but they cannot afford the HECS fee, particularly if they are adult students or mature age students. Most students are probably adult by the time they get to there. Let us look at how we can encourage and facilitate that because the cost of not having them is greater than the cost of providing the HECS relief.

Whilst the Government has strategies related to the delivery of health care in Tasmania, the committee also recommends the adoption of a long-term strategy specifically focusing on the poorer health outcomes experienced by Tasmanians living in rural and regional areas.

This strategy, and we do note the other strategy that the Department of Health has, and what we are saying here is that it needs to have a particular focus on Tasmanians living in rural and regional areas, because there is a difference. If you do not look at that difference and focus on it, it just gets swept into the overall figures, which gives a very unclear and inaccurate picture of the health outcomes for Tasmanians living in rural and regional areas.

The committee felt this strategy should take a person-centred holistic approach with a particular focus on preventive health and wellbeing that considers and responds to intergenerational factors, as I referred to earlier. As with any strategy, it is essential that the Government monitors, measures and reports the progress of health outcomes against both the recommended long-term strategy focused on Tasmanians living in rural and regional areas as well as all existing Department of Health strategies. Improving outcomes should be the priority in reviewing those.

One of the frustrations for those working in primary health, especially in rural and regional areas, is the reality that only a very small percentage of the overall health budget is allocated to this area. I did allude to that earlier. It is also important to note - and not forget that the Australian Government is primarily responsible for funding general practice and primary health care. Despite this, the committee received evidence that the Tasmanian government, and to a lesser degree, local government, have stepped in to provide some services to rural and regional Tasmania where services that should be funded by the Australian Government have not met the health needs of the community or they have failed. Whilst I commend the Government - and this is laudable of the state Government to do this - it does not ultimately address the underlying problem and is effectively a bandaid solution. Whilst I thank them for doing that, this cannot be the long-term solution.

Many general practices in rural and regional Tasmania no longer offer bulk billing of GP care. This is predominantly because the current Medicare Benefits Schedule (MBS) rebates are insufficient to provide financial sustainability for many rural and regional general practices. General practice is a business after all. They are in the business of providing care to people, but you have to run the business; you have overheads, you have the staff, the administrative staff; you have practice nurses who do not attract an MBS rebate. So, if the Medicare Benefits Schedule is not making it financially viable, why would they do it?

After years of training, why would they continue to do it in that sort of setting? This is compounded by the complexity of the patient's health status. The lack of access to GPs in many areas creates longer waiting times to receive care and the greater deterioration of the health of the patient as they wait to access care. This lack of access to Medicare provider numbers for general practice nurses and thus the capacity to fund essential health care provided by them has resulted in inadequate funding to cover administrative costs associated with operating many of our rural and regional general practices. Anyone who lives in a rural or regional area, when you go to your GP and have a chat about this, they will tell you. My general practice visits usually are taken up by quite a discussion about these things after we have dealt with whatever I am there for and I am quite happy to talk about it with them. I am not charged double. My consultation is usually as long as a double appointment, but I usually only get charged for the one because most of my issues are dealt with in that short time.

A GP practice that is expected to revolve around a six minute consultation simply is not viable or even realistic in a rural setting and that is how it is designed to work.

I am sure any of us who visit general practices where practice nurses work as well, who do not get any remuneration other than the whole practice can provide to them, would know the enormous and important role they play as part of the healthcare team in a general practice. This could be addressed by appropriate remuneration of practice nurses for the work they do within their scope that frees up the GP to focus on the medical issues that they are qualified to treat.

In the practice I go to, practice nurses are flat out the whole time and they provide a lot of the care that I go there for. This lack of financial support has contributed to the reduction of bulk billing of patients attending general practices in rural and regional Tasmania. This is where the rubber hits the road. Without bulk billing, the impact of the financial burden for those patients can, and does, further delay seeking care, resulting in more complex health conditions when care is sought. The alternative option for these patients is that they may attend the local hospital to avoid out of pocket expenses.

These factors contribute to the inequity of access to timely health care; they contribute to financial hardship for patients and families; they contribute to poorer health outcomes and an avoidable increase in demand on our acute health services. As the Australian Government is responsible for funding of the majority of primary health care provided in rural and regional Tasmania, the challenge is related to the inadequacy of the Medicare Benefit Schedule and the impact of the modified Monash Model and thus the cauterisation of many GP practices in rural and regional areas of Tasmania. This highlights the need for ongoing collaboration between the state and Australian governments and I would suggest, direct lobbying to try to address this.

A collaborative and innovative approach that is community-informed is needed to address poorer health outcomes and access barriers and to meet specific needs of Tasmanians living in rural and regional areas. In this area, the committee recommends the Tasmanian government continues to seek adequate funding to meet the needs of rural and regional Tasmanians, including lobbying for a dedicated rural health fund. I want to repeat that because this is something that could really make a difference.

If there was a rural health fund - this is predominantly from the Commonwealth and I am asking the state to really work on achieving this - that could be dedicated to dealing with and addressing these inequities of access, barriers to care and the inequities in health outcomes, that is what we need. A dedicated health fund or a single-funded model, where the Commonwealth give us the money and the state - as long as there is some dedicated to rural and regional services delivers the primary health care as well. I do not know how many years we have been talking about the dual funding model and how problematic that is. It has been ever since I have been in this place. I think someone really needs to have it. We do not want the federal government running our hospitals, we absolutely do not want that. The state runs services; the state runs hospitals but they can provide the funding to do it, particularly the rural and regional health care.

A dedicated rural health fund would go some way, not all the way, but some way to ensuring that the very real inequity of access and much poorer health outcomes for rural and regionally-based Tasmanians could help close that gap. I expect many of us would have seen recent media coverage regarding the Medicare Benefit Schedule and alleged misuse. That is a matter that will be investigated more fully, no doubt, but I know that there are very real challenges in the way the Medicare Benefit Scheduling currently works - or does not work for rural and regional general practice.

The MBS did have a review, it was commenced in 2015 and was completed in 2020. We had a look at the size and scale of that and it was enormous. It resulted in many reports and recommendations, too many to sit through for the committee. It was impossible to tell what had been implemented and what had not because there was a report for every section of the process.

However, the committee believes these reports and recommendations should be examined to ensure MBS rebates are fit for purpose and meet the increasing and unique needs of rural and regional Tasmanians. If funding gaps continue to persist and the needs of rural and regional Tasmanians are not adequately met, the Tasmanian Government should encourage further review of the MPS related barriers to workable health care in rural and regional Tasmania.

That needs to happen anyway because a one-size-fits-all approach to the MBS does not work. It might work in an urban clinic like in Melbourne and Sydney where you can ram through six-minute appointments and get the outcomes you need for those patients, but you cannot do it in a rural and regional setting. People are often too sick and have too many complex health conditions to do that.

I noted the additional challenge for health care workers and service due to the COVID 19 pandemic. However, as with all major challenges, different ways of doing things can emerge and some of these should be maintained to assist timely access to care. For example, a number of health care innovations - such as expansion of digital health services and expansion of the scope of practice for some health care professionals in response to the COVID-19 pandemic should be maintained to promote timely access to care and vaccinations beyond the COVID-19 emergency response.

This report contains comprehensive evidence, clearly describing the inequity related to the lack of access to care and the resultant poor health outcomes faced by Tasmanians living in rural and regional areas. The evidence is captured in the findings of the committee and they were consolidated, and I have spoken about most of those in broad terms.

There are a number of findings that I have not mentioned here. They are all equally important and I urge the Government and policy makers to consider and reflect on each one of those. The findings are organised into key themes and contain a succinct summary of the evidence.

Before concluding, I will refer to our recommendations. The recommendations have been consolidated to ensure action taken to address barriers to health care, timeliness of access, equity of access with a focus on improving health care and health outcomes for all Tasmanians. Clearly, there are marginalised groups within those communities who experience even greater barriers, access issues and poorer health outcomes. Actions taken as a result of these recommendations need to ensure the additional needs of specific communities, often within communities, are considered as part of that action, and requires deep and meaningful community engagement to achieve.

The committee made 13 comprehensive and inclusive recommendations to the Government, and I will briefly comment on each one. The first one is to adopt a long-term strategy to address the poorer health outcomes experienced by Tasmanians living in rural and regional areas, with a particular focus on preventative health and wellbeing; a person-centred and holistic approach; local community health needs; intergenerational factors; removing access barriers; and the delivery of trauma-informed care. The Government should monitor, measure and report health outcomes and progress against this strategy.

I have spoken about this previously. It is about monitoring these aspects, but reporting against it - with an additional focus on Tasmanians living in rural and regional areas. As we have seen from the evidence, having a statewide summation of the data does not paint a true picture.

The second recommendation was that the Government works with the Australian Government to establish collaborative and innovative funding models to meet the specific needs of individuals living in rural and regional areas. I mentioned this previously, particularly the consideration of a dedicated rural health fund; active support of multidisciplinary models of care; and avoidance of duplication of services and/or costs in areas where health services attract both Tasmanian and Australian Government funding. This is where we can see double ups, gaps and less efficient use of the available funding.

Number three: to take an evidence-based approach to identify health care needs in rural and regional Tasmania and strongly advocate for additional Australian Government funding to support the delivery of viable primary health services.

It is, after all, the Commonwealth's job but the way it is working at the moment - these primary health services like GP practices are not going to continue to be viable. That is why we have seen some close in our regional areas. Also, the additional funding to deliver community-centred alternative models of care and that includes multidisciplinary centres and other models such as PACER. That was a state government initiative. To support the recruitment and retention of primary health care providers: this is where the federal government can be involved but also the state Government, in supporting the HECs fees of some of our identified levels of workforce shortages and, importantly, avoiding shifting of costs and responsibility for these services to the Tasmanian Government.

I have spoken to the minister and Premier about this a number of times. The Australian Government should be funding these things but we are being almost forced to step in because, as a state government, you want people to have access to services. Hopefully, we will have a better response from the current federal government.

The fourth one: monitor, measure and report health outcomes to Tasmanians living in rural and regional areas against the Department of Health Strategic Priorities 2021 23. I have referred to that one already, in the first recommendation; to adopt a strategic approach to deliver integrated, multidisciplinary models of care, including mental health services that are community centred and specific, support health practitioners to work collaboratively, including the delivery of after-hours care, and do not rely on a fee for service. I have covered those in my contribution as being the important things that will make a difference and they should be a focus of the Government.

In collaboration with the Australian Government - there is a lot of cross over here address barriers preventing the full utilisation of the workforce. I will cover that in fair detail, particularly looking at any relevant legislation that may create legislative barriers; employment arrangements; funding arrangements; and ensuring that the scope of practice with regard to all health professionals is that people are able to work across their full scope. That includes nurse practitioners - noting that a nurse practitioner has an identified scope within their practice; rural generalists; and paramedics, including paramedic practitioners; and pharmacists.

Recommendation 7 was that, where appropriate, the Tasmanian Health Service adopt a single employer model that encompasses hospital, rural generalist and general practice services. I alluded to this, in that if a GP is working in general practice, working as a rural generalist and thus employed in the hospital as well, they have different employers. That makes it even more difficult. That could be addressed with collaboration with the federal Government.

As I have mentioned, we continually need to advocate and work to ensure the Medicare Benefits Schedule (MBS) supports the financial viability of rural and regional general practices. That is outlined in recommendation eight, and I have described what that looks like.

Recommendation 9 - to address specific workforce shortages, including in rural and regional Tasmania. That includes updating the Health Workforce 2020 40 strategy, which is an ongoing work - and making sure there is a focus on rural and regional areas, not just Tasmania as a whole - to develop flexible working arrangements to enhance worker retention, including an adequate time away from active duty; guaranteed peer support; and access to continuous professional development. You have to have so many hours of CPD, depending on your profession, to maintain your registration and licence to practice. We visited some of the hospitals around the state - the rural and regional hospitals and health centres - prior to commencing the inquiry. We went to St Marys where there is one GP. What happens if he is sick? What happens if his kids are unwell? What happens? There is no doctor to cover the hospital there. He needs time off, he needs a break. We know what can happen to people who do not take a break and burn out.

Ms Rattray - Even if they cannot take a break, you will recall what happened to Dr McGinity. He was struggling to be able to take a break.

Ms FORREST - Yes, single practices are no longer the way to go. That is the point here. Consider alternative models of funding and remuneration of health professionals in areas of high workforce shortage; address any career pathway limitations; and work collaboratively with UTAS, TasTAFE or other registered training authorities to identify and address key areas of workforce shortages. If you look at the list, there are 13. Take your pick. There are workforce shortages everywhere in health.

Recommendation 10: to actively consider funding the higher education contribution costs of nursing, midwifery and allied health undergraduate students; and provide scholarships for postgraduate studies, including nurse practitioner specialties and allied health professionals, in areas of identified workforce shortage.

That is broader than what the Victorian Government announced a while ago, but we have much greater challenges in our rural and regional areas in accessing allied health and other professionals beyond nurses and midwives.

Recommendation 11: work with the federal Government to improve access to digital healthcare in rural and regional Tasmania. Digital health is a very important part of the future; but where you do not have good internet connection or you do not have the set-up in a rural hospital to have cameras over the bed in the emergency or urgent care rooms, that can then be linked back to a specialist in some other place - it could be Hobart, Launceston, Melbourne, it does not matter where they are - that can observe the patient and what is going on in live time, then you may not get the best outcome you could for that patient. So, we need to support our doctors and health professionals who choose to work for us in our regions, by making sure they have good equipment and good connectivity. Then we need to help the communities in rural and regional Tasmania, who have low levels of digital literacy, to also be able to engage with and use it.

That is a big body of work that requires social as well as physical infrastructure; but it will make a significant difference. We also need to ensure communications related to the availability of health services in rural or regional areas are clear, contemporary and accessible. Sadly, some of the websites are not kept up to date and people find it hard to find out where they can access services. It is a pretty simple thing but it would make a difference.

The last recommendation was to consider the employment of health systems navigators, particularly in rural and regional Tasmania, to assist individuals and families to find and engage with appropriate health professionals and services. Mr President, any of you who have helped someone navigate a health system - as I did with my elderly parents a number of times - know how difficult it must be for people who do not know the system, or who to go to next, or how to access care, or where they can get a particular service, or do not know how to argue the point about a particular decision that might be suggested or made.

I see a role here, perhaps for retired nurses and other health professionals who may wish to assist patients to know where to go next to get reliable, accurate information - not necessarily information from the neighbour or the person at the post office who might think they know best, and that may send them off in a path that does not help them in a timely manner.

I know I have said a lot about it, but it is a big report and it is very important. I acknowledge that a number of actions have been taken by the Tasmanian Government in response to growing demand in health care. I am not saying otherwise; and it is an ongoing challenge with demand continuing to grow. This is particularly the case in rural and regional areas.

We know that initiating an inquiry into matters can help focus the attention of Government and we look forward to the Leader's response on behalf of the Government as to what is being done during, and since the work of the committee commenced, as well as the plans for the future. However, the evidence is clear: a dedicated focus on and direct action to address the lived experience of Tasmanians living in rural and regional areas who, at times, faced insurmountable barriers to access timely and quality healthcare, must be a priority. As I noted earlier, without specific and targeted urgent action, the comparatively poorer health outcomes and mental health outcomes for those Tasmanians living in rural and regional areas is likely to get worse, and Tasmanians living in rural and regional areas deserve better.

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