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Joint Select Committee on Northern Australia - 19/08/2014 - Development of northern Australia

COATSWORTH, Dr Nicholas Richard, Acting Executive Director, National Critical Care and Trauma Response Centre

NOTARAS, Dr Leonard George, Chief Executive, Department of Health, Northern Territory


CHAIR: Welcome. Although the committee does not require you to give evidence under oath, I advise you that these hearings are a formal proceeding of the parliament and warrant the same respect as proceedings of the respective houses. The giving of false or misleading evidence is a serious matter and may be seen as a contempt of the parliament. We are being recorded by Hansard and evidence given today is covered under parliamentary privilege. Do you have any comments to make on the capacity in which you appear?

Dr Notaras : 105 days ago, I was the executive director of the National Critical Care and Trauma Response Centre; now the CEO of the Department of Health.

CHAIR: I invite you to give a short opening statement and then we will go to questions.

Dr Notaras : Thank you to the joint selection committee for the opportunity to speak today. The National Critical Care and Trauma Response Centre was established following the Bali tragedy in 2005—the first Bali tragedy being 2002. It was an initiative that I jointly worked through with the then Prime Minister John Howard. From that time, surrounding Royal Darwin Hospital and its capacity to respond to the possibility of another Bali type incident or a local catastrophe or disaster, we built the centre. Tragically, it was called upon to respond to the 2005 Bali tragedy. Subsequent to that, we have seen a number of different responses; most recently, towards the end of last year at Tacloban and the disaster with Cyclone Haiyan. Going back to 2010, the centre responded to the Pakistan floods and earthquake and a number of other well-documented incidents and issues.

The committee is basically an Australian government funded initiative which is well supported by the Northern Territory. It is all about being equipped, prepared and, indeed, practised to respond to a whole range of contingencies and incidents. That said, the centre itself provides a nationally unique and, indeed, internationally unique rapidly deployable and self-sustaining asset. I believe that later this afternoon members of the committee will visit a live display of—

CHAIR: We will not be able to do that, unfortunately.

Dr Notaras : Understood.

CHAIR: We tried to compress too much into the time frame. We had to withdraw that yesterday, knowing that you were here today.

Dr Notaras : We can well table for the committee a DVD presentation that is around it. We do not have those with us today, but we do have the capacity to do that in the next day or so. That will help inform the committee. I would suggest that the centre has evolved in a very quiet but deliberate manner, being available for deployment. As recently as two weeks ago, with the tragedy of the Malaysian airline disaster in the Ukraine, we were asked if there was a possibility of providing some medical support for the Australian Federal Police team that went there. That did not come to pass, but we were prepared with very short notice to be able to do that. The beauty of the centre is the capacity to have a rapidly deployable, well-trained team of nurses, allied health professionals, logisticians and doctors who can respond to particular disasters. They are drawn from right around the nation, not just from Darwin but from other jurisdictions—indeed, also from New Zealand.

The centre nowadays is built upon the premise of response, which is about 10 per cent of what the centre would do. There is education, training, exercising and partnerships with other facilities, such as the Princess Alexandra Hospital in Queensland, the Alfred in Victoria, the WA response facilities and so on. That is about 70 per cent of what the centre does. About 10 or 15 per cent is about research. That research surrounds pretty critical areas, particularly in tropical medicine, such as heat and the ability of first responders to be able to respond in difficult circumstances.

Drawing all that together, we were described by Ken Henry about two years ago, when he was preparing the report for the then Prime Minister Gillard, as a hub ideally situated to our northern neighbours, particularly Timor and Indonesia. Again, given the responses, whether it be to the Solomons last year with the dengue outbreak or to the Philippines or any of the other centres, we are certainly able, using military assets or domestic assets, to travel to other places. We have a very close relationship with WA and a close relationship with Queensland as well. I would say that all of the states and the other territory, as well as New Zealand, utilise our training. Indeed, when Cyclone Yasi tragically struck Queensland the year before last, we were able to supply first responders with equipment that was necessary, and we offered—and this was initially accepted—the use of our 100-bed, or so, fully air conditioned hospital. That said, all of the facilities that we have are designed around the premise of being able to be self-sustaining, rapidly deployable and not a drain on the local community, and we practice exactly the same with the teams that we send. The teams are fully trained and inoculated. They are people who are appropriate to a response; so each response that would occur has a team that is appropriate to the area which they are responding to.

I might hand to Dr Coatsworth, to Nick, and ask him to make a couple of comments. I make the additional comment that Nick, or Dr Coatsworth, has a background with Medecins Sans Frontieres and was in the Congo and other areas before coming to Darwin and joining the centre. He also headed a significant part of the disaster response last year to Tacloban and also a more locally based response, which Mr Snowdon attended, which was addressing some very serious trachoma issues in the Maningrida community. If I may, Chair, I will hand to Dr Coatsworth.

Dr Coatsworth : Thank you, Len, and I echo your thanks to the committee for allowing us to present today. I might drill down a little on the response to Typhoon Haiyan, particularly given that we need to paint a picture for what that field hospital actually looked like. It was one of the largest, if not the largest, deployments of a government-civilian field hospital ever. It reached Tacloban City within seven days, which, if not the fastest, was very close to it in terms of deployment. It was testimony to the relationship that we have internally with the NCCTRC, Emergency Management Australia and Foreign Affairs. The fact that these three agencies have all worked together over the past three years and can streamline a response to send in a team, 30 tonne of equipment and 30 personnel is testimony to how far we have come. We were visited at the time by the Filipino President, our own foreign minister, Ms Bishop, and various other senior dignitaries as they came through and recognised the professionalism of the staff and the fact that this is likely to be the standard for civilian-government funded field hospitals in the world.

I think it is testimony to the work that everybody has done over the past five years and to the leadership of Len. The output was phenomenal. Approximately 2,300 people were seen throughout facility. The partnerships with the local ministry of health were very valuable. The fact that we could provide a trauma facility to supplement a hospital that had been essentially destroyed at the top level and at the ground and first levels meant that, for the first four weeks post disaster, people could rely on a standard of surgical care that would have been completely absent had we not been there. If I can translate that: although we are very fortunate not to have had a disaster that has overwhelmed state capacity in Australia, we well know from Hurricane Katrina and Hurricane Sandy in the US that this can happen and it may happen to the top end of Australia. So, whilst you can be defined by your last mission, which is overseas, this is a truly national capability that we stock up here in Darwin for deployment, if necessary, across Australia. To that end, we are putting forward a proposal to have a multijurisdictional exercise with Urban Search and Rescue in 2016, probably located in South Australia, involving a casualty situation that would require the deployment of the entire field hospital from the NCCTRC. I think that is worth noting.

To summarise: when we previously sent teams overseas or interstate, it was very much focused around people who could do what they said they could do. They were specialists in their area. They were not necessarily trained in the area of disaster medicine—and this is the first thing. That is what we have provided through the Australian Medical Assistance Teams training. The second thing is that they went under state banners. Team Bravo for the Tacloban response was the first time a multijurisdictional team representing every state and territory had been deployed overseas in a civilian disaster response. I think at every level, including up to the Australian Health Principal Protection Committee and the ministerial level, it was lauded as something that had not been done before and was a model for future deployments. Australia can be proud, and particularly the Territory can be proud, of the asset that we have up here.

CHAIR: Very good, and thank you very much indeed. Who wants to start off questions?

Senator IAN MACDONALD: How are you funded? How do you operate?

Dr Notaras : We are funded through the federal government. It comes via federal Treasury to NT Treasury, and then the funding comes to the centre. Part of that funding is expended on the capacity within Royal Darwin Hospital—in other words, additional nurses, allied health professionals and doctors. Some additional funding goes to some relationships we have in other places such as Queensland and, indeed, previously, with the Alfred. Then the rest of the funding goes to maintenance of the day-to-day staff in the centre itself, which accounts for about 30, and also for expenditure on what we describe as the cache—the equipment that we would need for a response at any particular time. So the funding is a block. It is approximately $17½ million out of federal Treasury through NT Treasury and then to us.

Senator IAN MACDONALD: Then, when you are on a mission, you are supplemented—

Dr Notaras : Correct. As the result of a mission—for argument's sake, take the Solomons or indeed Tacloban recently—we will be given the opportunity, through either DFAT or indeed Emergency Management Australia, to submit relevant invoices, for want of a better word, and those would be analysed in terms of what is over and above what might be expected to be our core. So we would not be purchasing a new hospital each time. We would use the resources that we have: the generators that we have, the sterilisers and so on. But we may well, if something were to be damaged, seek to replace that, or, conversely, generally look at consumables and the cost of staffing, because we will be bringing people, as Nick well described, from other places. Team Alpha, the first team that went up to Tacloban, of approximately 2,730, was largely drawn from the NT, whereas the second team was largely drawn from across the nation. Then we would be seeking for those salaries so that we could pay—

Senator IAN MACDONALD: When you took that first team out, was there a gap in the services that they would normally—

Dr Notaras : No. That is a very good question. There was actually a crossover, and the crossover worked on a couple of levels. There were two parts. The first part was where both teams had an opportunity to meet and basically coincide and hand over their experiences, and then there was a brief period of a day or two days where the team leaders, the two most significant individuals from the first team and the second team, were able to basically pass on their information.

CHAIR: From the time of there being a request for assistance to deployment on the ground, what is generally the time frames that you are working on?

Dr Notaras : The beauty of the centre is that, should you request a response now that is appropriate, say, for an earthquake in Bali or something to that effect, we can actually have a team drawn together within approximately 24 hours, depending on the size of that particular team. If we are drawing on resources from across the nation, that could take two days, in terms of bringing people to this place. It will depend on the size of the team, because there are two or three different stages—perhaps four. One is what I would describe as a look-see or forward assessment team, of somewhere between four and six individuals, who would go up and do, if necessary, a forward analysis. The second team is a team that is much larger and could be anything from 16 to 24 or 30, and there is a possibility for us to put in a much larger recovery team. That particular team would take anything up to 40 or 50 individuals.

Dr Coatsworth : As to the actual stats from Tacloban: we were activated by the interdepartmental emergency task force at 11 am on Monday, and we had the full team assembled in Darwin by midnight that night. All the equipment was at RAAF Base Darwin by 0100 hours that night. The delay then became access to the Tacloban city airport.

Quite frequently the delay in these situations is political, but the reason we need to activate so quickly is that within country in Australia we will not have those political barriers and we will be expected to react with a rapid response team within six hours and then an extended response or surgical team within 24 hours if there is a catastrophe affecting Far North Queensland or north-west Western Australia or, indeed, a cyclone rolling over the Top End. So we base those response times on what we need to do in Australia and then our good colleagues at Foreign Affairs take care of the stuff overseas. But that is the delay.

Ms MacTIERNAN: With the facility set up at Tacloban, do you bring that back at the end? Is all of that repackaged and brought back?

Dr Coatsworth : Yes. We have a very good relationship with AQIS, who tell us exactly what we can and cannot bring back. Emergency Management Australia helped facilitate that and everything was quarantined at RAAF Base Darwin and cleaned. There is a moderate risk of equipment being offline, so one of our strategic ambitions is to have a degree of redundancy with the field hospital and duplicate some of the equipment that we have managed to amass over the past five years. That is something we need to consider.

Dr Notaras : On the response last year, we were responding almost simultaneously to the Solomons and to Tacloban, which really had used up or at least committed most of our deployable assets by that particular stage. As Nick says, one of the visions is having a close link in conjunction with WA and Far North Queensland, with the real possibility of additional hubs. This is something we have discussed with our colleagues in both Queensland and WA.

Dr Coatsworth : One specific example on the table at the moment that we are discussing with WA Health and Inpex is a public-private partnership to replicate, not in its entirety but a disaster medical cache, at Broome and at Truscott airbase. That would be for local-regional responses predominantly affecting Australia and Australians if they were out in oil rig disasters and so forth. That is the sort of vision that we have, that this can expand under the aegis of the NCCTRC but with our colleagues in Queensland and WA. That accounts for the primacy, if I can use that word, of our relationships with those states or some of the southern states, all of whom we have relationships with.

Ms MacTIERNAN: But you have to be realistic about the replication of those costs.

Dr Coatsworth : Correct.

Ms MacTIERNAN: Wouldn't it be better for you just to be travelling across to there?

Dr Coatsworth : It would be. Proximity is also a major issue. We would not replicate a full surgical field hospital over there. It would be a much smaller modularised version of what we can take over. We can build from the bottom up, either a primary care facility or add on a ward or add on a field hospital. It would be ridiculous to replicate the field hospital because in fact there are very few of those in the world. You do not actually need one country to be custodian of two of them, but you do need a smaller cache, I think in Far North Queensland or north-west WA, that we can supplement if the need arises.

Ms MacTIERNAN: You said that part of this preparedness was having people that had been inoculated. Did I hear that right?

Dr Notaras : Yes, you did.

Ms MacTIERNAN: So you have a suite of people that have had a full range of typhoid, cholera—is that how it works?

Dr Notaras : Exactly. Previously, if we go back to some of the natural and other disasters that have occurred, there have been a number of willing people very prepared to say they are available to respond. We found this during the preparation for the Pakistani response: as soon as it became known nationally in the media we had people ringing from all over the nation saying they were very prepared. For the safety of the individual and the efficacy of the response we have very strict criteria as to who might go where, with typhoid, cholera, rabies, a whole host of appropriate inoculations for appropriate areas. This is part of the whole course that we put individuals through. They will go through an austere suite of training that will prepare them for a response and what to expect in that response. As well as that we would expect them to have knowledge of the security of the area and be fully inoculated in the event of exposure to any of those issues.

Ms MacTIERNAN: The inoculation is one you would have to do some time in advance, isn't it?

Dr Notaras : Absolutely. We have now somewhere in the vicinity of, just here in the Darwin area, 300, I think it is. But across the nation it is closer to 500.

Ms MacTIERNAN: That have had the full suite of—

Dr Notaras : Full suite of training, inoculation and so on. As we speak, Dr Ian Norton, who was a predecessor as my deputy and indeed was one of the leaders of a number of teams, is still employed by NCCTRC in Geneva, working with the WHO, consolidating the ability of the WHO to be able to have a standard training and preparedness response for what you might expect of foreign medical teams attending disasters. They are a set of standards that we are actually helping formulate at a WHO level.

Mr SNOWDON: Perhaps I could just ask about the team preparedness. You just mentioned 500 people across the nation. They have all been accredited, gone through the training exercise, ticked the box and said, 'I'm volunteering when I'm called upon.' So, they would be the full range of specialties, presumably—allied health and nursing.

Dr Notaras : Correct.

Mr SNOWDON: So, do you have a priority list—a ready reserve, if you like?

Dr Coatsworth : The priority list is effectively from the NT, and there is a number of reasons for that. Clearly people live here, but the breadth of experience that NT practitioners have, like those who practise in the other parts of northern regional Australia, tends to be what you need in a disaster response. So, Team Alpha will almost invariably be predominantly from the NT, followed by people from the southern states. Who we actually take often depends on the disaster. If we went to the Ebola outbreak they would be different to the people we took to Tacloban. But they are all prepared. We are moving away from the use of the term 'volunteer', because they would actually be seconded, effectively, by their state health departments to the Commonwealth and be deploying as salaried Commonwealth officers. So, it is the whole idea of having that professional government response—

Mr SNOWDON: Presumably they are not all government employees. There would be a lot of people in private practice who are working for government on a sessional basis or whatever. So, is there an issue with employers giving people an opportunity to do these jobs when they arise?

Dr Coatsworth : By and large the state health departments have been supportive. The majority of our staff are publicly employed. There are a few private ones. The issue we have is cross-jurisdictional awards—that is the major one—and trying to account for those when you are on a different sort of roster and that sort of thing, and that is work that we are working through at the moment. But that would be one of the primary issues that we have to sort out.

Dr Notaras : There has seldom been an issue that could not be resolved by a telephone call. Quite often we can be taxing, particularly with out local logisticians, who happen to be fire officers and police officers here with the Northern Territory police, fire and emergency services. The issue there can be our demand when they have other demands at the time. But I have to say, they are always more than helpful in responding and there has not been anything up to this time that has not been able to be sorted with a telephone call.

CHAIR: Once you have trained them up, do they come back periodically for advance training or refreshers?

Dr Coatsworth : They do. Quite often we will bring people back as faculty. Quite often as the states develop their own AUSMAT courses and we support them they move into faculty for their own jurisdictions. We are now getting to a sort of four- or five-year period after the first AUSMAT course, so there are going to have to be refreshers. But there are clinical team leader and advanced team leader courses as well. That is all in acknowledging that the programs have been around for a relatively short period of time and are still in development.

Mr SNOWDON: What about the interaction with the military and the relationship with Defence?

Dr Notaras : We have a very close association with the military. The military has facilitated pretty well all of our uplifts. We have come back on domestic civilian when things have settled, but a number of our responders are also reservists. Our orthopaedic surgeon, for instance, is a group captain with the Air Force and has been in Afghanistan and Iraq, and a number of our other folk are reservists or have previous military training. We work very, very closely with Defence.

Mr SNOWDON: That is also true for on-carriage?

Dr Notaras : Yes.

Mr SNOWDON: So, if you need a C-130 or—

Dr Notaras : Yes, absolutely. We used a C-17 and a C-130 for the deployment to Tacloban. The interesting part about that as well was that on arrival up there Team Alpha found that the site had been secured by the US Marines, the same US Marines we had worked with here in Darwin. So there is a close association and relationship with them. As well, through an initiative a year and a half ago that Dr Coatsworth came up with, we have also been training through an ASEAN link doctors and other support from the Philippines and Singapore.

Dr Coatsworth : We have to have that expertise and civil military collaboration. I think we had 12 different countries represented from the ASEAN military medicine group and that included people from as far afield as Russia. That is critical because although we often use defence in partnership, our colleagues to the north will use defence as their primary response.

Mr SNOWDON: Has there been any discussion between you and your team with Navy and the new Canberra class vessels?

Dr Coatsworth : We have had discussions in as much as some of the leaders of that project were with us for our advanced team leader course last year and presented on it. They certainly sounded very keen—and we should pursue that—to have us on board in any sort of joint response. They would be an ideal facility if they were in the right place at the right time.

Mr SNOWDON: They will be able to be moved—do not worry. I have been associated directly and indirectly with this group since their establishment and I want to say thank you for your magnificent contribution and for what you have done for Australia.

CHAIR: Thank you very much indeed and thank you for the submission and the evidence you provided.

Dr Notaras : We will table the documents we have.

CHAIR: Yes please. We will make sure they are incorporated.