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Senate Select Committee on Health - 29/04/2016 - Hospital funding

GREENAWAY, Associate Professor Tim, President, Australian Medical Association Tasmania

Committee met at 09:33

Evidence was taken via teleconference—

CHAIR ( Senator O'Neill ): I hereby open this hearing of the Senate Select Committee on Health. I welcome you all here today. On behalf of the committee I would like to acknowledge the traditional owners of the land on which we meet and pay my respects to elders both past and present. I also extend that respect to Aboriginal and Torres Strait Islander people present today.

This is a public hearing and a Hansard transcript of proceedings is being made. The hearing is also being broadcast via the Australian Parliament House website. Before the committee starts taking evidence, I remind all witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It is unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee, and such action may be treated as a contempt. It is also a contempt to give false or misleading evidence to a committee. The committee generally prefers evidence to be given in public, but under the Senate's resolutions witnesses have the right to request to be heard in private session. If a witness objects to answering a question, the witness should state the ground upon which the objection is taken, and the committee will determine whether it will insist on an answer, having regard to the ground which is claimed. If the committee determines to insist on an answer, a witness may request that the answer be given in camera. Such a request may of course also be made at any other time. I would also ask witnesses to remain behind for a few minutes at the conclusion of their evidence in case the secretariat staff need to clarify any terms or references. I remind people in the hearing room to ensure that their mobile phones are either turned off or switched to silent.

I now welcome Professor Tim Greenaway, president of the AMA Tasmania. Would you like to make an opening statement? The committee will follow with questions.

Prof. Greenaway : Not specifically. The reason I did not put in a written submission is that until late on Wednesday night I understood that I was due to appear before the full bench of the Tasmanian Industrial Commission regarding a matter before the commission, and I was not expecting to give evidence to the committee. So I apologise for that. This has been organised in the last 24 hours and I have been caught up with clinical work. I am on call at the Royal Hobart Hospital and therefore I have been unable to appear in person.

My evidence will largely be to update the committee on evidence I gave previously with respect to the projected effects of the parliamentary budget cuts to health. We would need to consider the recent COAG agreements and the additional $2.9 billion that has been earmarked for health over the next three years. The original evidence I gave was specifically to do with the effect of the 2014 budget, the shortfall and the effects of that shortfall on the Tasmanian public hospital system. So the evidence that I will give will focus on the recent Australian Institute of Health and Welfare data, with respect specifically to the Australian hospitals statistics for admitted patient care 2014-15, which is on record, and to the performance and activity of the Tasmanian public hospitals in light of the 2014 budget, the more recent COAG agreement and additional funding, which will not be sufficient to address the inequities that the Tasmanian public hospital system faces.

CHAIR: Sorry, did you say it will not be sufficient to address the inequities?

Prof. Greenaway : Yes. The Parliamentary Budget Office has calculated, using national figures for activity, that the effect of the 2014 budget would be that Tasmania would lose $1.151 billion over the eight-year period from 2017-18 to 2024-25. Of the additional $2.9 billion from the COAG agreement, $54 million over three years will go to Tasmania. But if you look at the AIHW data, Tasmania has fewer public hospital beds per thousand patients, increased activity and an older, sicker and poorer demographic which relies on the public hospital system more. The shortfall, even allowing for the additional $54 million from the COAG agreement, is still going to be quite devastating to Tasmania. The AMA, on both the state and federal levels, will be obviously pursuing the issue of securing adequate funding for the public hospital system into the future as a major item in the forthcoming election.

CHAIR: Thank you very much for those opening remarks, Professor Greenaway. I think Senator Cameron wants to ask you some questions directly.

Prof. Greenaway : Sure.

Senator CAMERON: Thanks, Professor Greenaway, and thanks for attending today. I suppose some of the figures that we are talking about, like the $54 million—most Tasmanians, they would just go glassy eyed; these are figures that do not mean a lot to them. When you indicated that the shortfall will still be devastating, what does having that shortfall for services mean in practical terms to the Tasmanian public?

Prof. Greenaway : Thank you for the question. If you look at the AMA report card on the public hospital system, you will see that Tasmania performs very poorly with respect to waiting times for elective surgery, for example. The effect of inadequate public funding is that elective surgery, for example, and elective reviews are constrained by the need to deal with urgent cases when there is a capacity issue. If you look at the AIHW data, look at the performance of the Tasmanian public hospital system, we are actually not inefficient. Our relative stay index is one, which means it is right slap bang on the national average, but our weighted separations are higher, which means that Tasmanian public hospitals treat on average more complex patients, sicker patients, more expensive patients, but more quickly than the national average—or at least as quickly—but they are more complex than sick patients.

We have inadequate capacity, so any funding shortfall means that elective procedures are put on the backburner, as it were. We do not deal with elective cases; we are forced to deal with acute cases. If I can give you an example from my own hospital today, as at 29 April we do not currently have any beds. At about 7.30 this morning an SMS was sent to every consultant on call saying that we have a crisis in the bed situation at the Royal Hobart Hospital, and could everybody work especially hard to try to discharge any patients who would be suitable. And we are not even in winter!

The effect of funding shortfalls in the public hospital system will be felt more acutely in Tasmania than in large metropolitan areas on the mainland—Sydney, Melbourne, Brisbane et cetera. We have an older, sicker, poorer population who rely more on the public hospital system, and yet we have fewer public hospital beds per 1,000 of the population. So any funding shortfall is going to be acutely felt in Tasmania, and it will be the acute services affected, the waiting times will increase and elective surgery lists will be cancelled, as they have been already. This is the future that we see.

Senator CAMERON: You hear a lot about virtuous circles, where you actually spend the money and that creates this reinforcing loop that makes things better. But you seem to have the opposite here, like a vicious circle where the money is not there; it will cost more money; health outcomes will be less. It just seems to me that you have this vicious circle in Tasmania in terms of health—would that be correct?

Prof. Greenaway : Yes, it is, and that is not to say that we are not acutely aware of the need to improve and to focus on primary care and preventative health, as it is termed, and improving the health of the community. Public hospitals are often places of last resort if you like, when the chronic conditions become more acute and people require in-patient or specialist care. So the AMA is very mindful of the need to improve public health generally, and that is particularly an issue in Tasmania. I chaired the Healthy Tasmania committee, and I am deputy chair of the Health Council of Tasmania, which is focusing on responding to a state government initiative with respect to work in the public domain, or at least to try to improve public health measures. This needs to be done in conjunction with looking at the capacity of the public hospitals to deal with the waiting times that exist already. So you are right; we do have a vicious circle at the minute, with inadequate resourcing and inadequate numbers of nurses to look after patients. When we have acute issues, a bad flu season for example—if we get that this winter, then I can absolutely guarantee that the Royal Hobart Hospital and Launceston General Hospital will basically grind to a halt and we will be dealing just with acute issues and acutely ill patients, and we will not have the capacity to deal with elective surgical lists.

Senator CAMERON: I want to go to the issue you have raised about primary care. We have heard lots of submissions saying that if you get primary care right, then it reduces the impact on hospitals and that hospitals are the most expensive means of dealing with medical problems. But we have now got this cutback in bulk-billing in pathology and imaging services. If people will not access pathology and imaging services because it could cost them $100 for an X-ray, then surely that is a problem for effective primary care in Tasmania?

Prof. Greenaway : Yes. As you would be aware, the AMA is on record as wanting the incentives for bulk-billing for imaging and pathology maintained, particularly for the reasons that you have outlined. The modelling that has been done would suggest that that will affect people with chronic conditions, particularly those in poorer or regional areas, who would potentially avoid having the monitoring tests that are necessary to care for their chronic conditions. That does then raise the spectre of chronic conditions becoming worse, or more acute, and requiring expensive in-patient hospital stays. To extend on the thing that you have raised: the freeze on the Medicare rebate, which has really put strain on the general practice and general practitioners and bulk-billing rates around the country, is something that the AMA opposes. While we support the initiative of the patient home and the primacy of the general practitioner in managing patients with chronic conditions, we are awaiting detail regarding the funding. The primary care providers, the general practitioners, need to be funded adequately to look after patients with chronic conditions in the community to avoid unnecessary and preventable admissions to hospital, as you have said.

Senator CAMERON: Was there any consultation with you or with your colleagues in relation to the proposition that Malcolm Turnbull put forward—that is, that the states could fund their own hospitals? Was there any discussion with you on that? Have you got any views, if that re-emerged as a proposition, as to how it would affect Tasmania?

Prof. Greenaway : Only insofar as I have—I am also a member of the federal AMA council, and we did meet with the Prime Minister and the health minister at the most recent federal council meeting. I put it to the Prime Minister directly that Tasmania was not in a position, without Commonwealth support, to adequately fund health and that the principle of equity of access to quality health care is fundamental. I would imagine that we would all support it, yet in the smaller states, such as Tasmania, clearly Commonwealth funding is going to be necessary to allow Tasmanians to have the same sort of access to quality health care that people in metropolitan Sydney and Melbourne, for example, enjoy. So, no, there wasn't specific consultation but the Prime Minister, I am sure, and the health minister were under no illusions as to what I thought about the issue.

Senator CAMERON: They may have been under no illusion about what you thought about the issue, but did they give you any response to your arguments, because basically this is an argument on, in the economic term, horizontal fiscal equalisation principles, and that is that a place like Tasmania has geographic disadvantages and intergenerational disadvantage. Did the Prime Minister understand that?

Prof. Greenaway : I believe he does, yes, but you are quite right, that is the traditional argument for the additional GST revenue that Tasmania has enjoyed specifically to help with the funding of health in the state. That having been said, it is interesting, and nobody has picked this up, that the $54 million additional to 2020 from the COAG agreement represents less than our traditional 2.2 per cent, given that these things, as I understand it, historically seem to have been allocated on the basis of population, and Tasmania has 2.2 per cent of the population. By my calculations, 2.2 per cent of $2.9 billion is $64 million—I do not know where the other $10 million is gone. I guess that is something of a moot point. But, yes, when we have pointed this out, the Commonwealth has traditionally said that the specific issues that pertain to Tasmania are the reasons for the additional GST revenue.

Senator CAMERON: You said that the Prime Minister understood the issues of horizontal fiscal equalisation. If he did, did he give you any reason why then it was cutting back on what would be a share of the budget to provide decent health services in Tasmania?

Prof. Greenaway : No, he did not. But to be fair to the Prime Minister we were talking at federal council about national issues. Obviously I asked the question as the AMA president for Tasmania about Tasmania, but it pertains to South Australia as well, obviously, particularly. But we were talking more broadly, so I did not have the chance to focus on Tasmania and Tasmania's problems other than the initial question to the Prime Minister that I was allowed to ask.

Senator LAMBIE: Do you agree that the Launceston General Hospital and the Royal Hobart Hospital are already operating at 100 per cent capacity?

Prof. Greenaway : Yes, I do. If you look at the figures that we have for bed occupancy rates, for some considerable period both hospitals have been operating at 100 per cent or more at some period.

Senator LAMBIE: Would you agree that the state Liberals' health plan, behind all the fancy words, is to run down and redirect acute medical services from the Mersey hospital to the Launceston General Hospital and the Royal Hobart Hospital, which you have just admitted are already running at 100 per cent capacity?

Prof. Greenaway : The issue is a complex one. What we are talking about is a role delineation of basically directing care to where it is most appropriate to give that care—that is, to get the patient to the facility that is capable of best delivering the care. But if I can extend I think on the reason behind the question you have asked, as you know, under the white paper that the state government has proposed, which the AMA supported, the Mersey would be a facility for elective surgery for the state, but the role delineation that is the subject of the white paper and the reforms in Tasmania will only work if there is adequate resourcing, particularly of the Launceston General Hospital, which is expected to support the North West Regional Hospital and the patients in the north-west of Tasmania. I have a meeting with the health minister next week specifically to look at these issues and in particular the AMA's view that we need to resource appropriately the Launceston General Hospital, for example, to support the north-west. We support role delineation, but it needs to be married with appropriate resourcing.

Senator LAMBIE: Are you aware of Aspen Medical?

Prof. Greenaway : Not specifically. What is the context?

Senator LAMBIE: They are the people who have gone in and cleaned up South Australia's waiting lists and have been able to maintain that list right down. They have also been involved in the Ebola crisis and have sorted all that. In the last six months I have asked Will Hodgman to bring Aspen into our medical centres. They can come in here for about two months and go through everything. They work in conjunction with you people in the hospitals and the nursing staff. They do that for about $15,000. They come in and do a massive assessment so they can get those waiting lists down. Are you opposed to the government's plan to use the five private providers that we have spent quite a considerable amount of money on when we have a proven identity out there—Aspen Medical—and we should be using them? By the way, that $15,000, just so we are all clear, is a one-off payment, that, if we take them on to sort out the hospital system, gets wiped.

Prof. Greenaway : That is a very complex question. As you know, the Tasmanian government is outsourcing public hospital elective surgery at the minute to private providers, specifically in Melbourne. You can understand the sensitivity of the government—I already mentioned that the Tasmanian waiting lists for public surgery are the worst in the country, so I absolutely understand their sensitivity to this and their wish to reduce public hospital waiting times—but the way they are doing it is not building infrastructure in the public system for the future. The risk with doing something like what you have suggested, which is using Aspen as a private contractor, if I understood you correctly, to reduce waiting times, does deal with the short-term problem but will not affect long-term issues. The long-term issues of a chronically sick population—older and with poorer health literacy and poorer resources—mean that there will always be a demand on the public system for care. What I would prefer and what the AMA would prefer is that as well as money spent on an acute fix to the public hospital waiting times there is resourcing of the public system so that it can better cope with demand in the future. It is a very complex issue, but whilst I do understand the attraction of getting dealt with patients who have been waiting inordinate times—years sometimes—for their elective procedures, we have to think of the longer term and the future of the public hospital system.

CHAIR: Professor Greenaway, are you able to stay with us for a few minutes longer? Our next witness has not yet arrived.

Prof. Greenaway : I can. I am with some research patients; I have one of my registrars dealing with it. I can hang around for a few more minutes if the committee would wish.

CHAIR: Wonderful. So another question from Senator Lambie and then I might have a couple to conclude. Thanks.

Senator LAMBIE: Professor Greenaway, the national average is 2.6 public hospital beds for every 1,000 head of population, which means Tasmania should have 1,318. Instead we have approximately 1,188 public hospital beds with attached medical professionals. Do you agree that, just to reach the national average, Tasmania needs an immediate increase of 145 properly funded and clinically staffed public hospital beds, and that they will come at a cost of about a million dollars a year per head?

Prof. Greenaway : I absolutely agree with your comments, although I cannot quote the cost that would be entailed by the increase in the public hospital beds. The other thing the committee should realise is that the number of public hospital beds does include the smaller regional hospitals as well as the four major public hospitals in Tasmania. But you are absolutely right—we do not have adequate public hospital beds, particularly in the larger hospitals.

Senator LAMBIE: Just so you know, we have actually done the library studies on this and, obviously, we have got costings from PBR to say it will be a million dollars per head. We are about 145 beds short here in Tasmania.

Prof. Greenaway : Well, I respect the costings, but we are certainly short of public hospital beds. There is no doubt about that at all.

Senator LAMBIE: Thank you.

CHAIR: Professor Greenaway, you indicated something that we have been hearing around the country. In Campbelltown just a few weeks ago, doctors were directed to expect that they will not be doing elective surgery throughout the winter due to a similar situation—bed capacity already met. You talked about what this means to Senator Cameron in response to his question about the quite devastating impacts of these cuts to funding here. Can you explain what elective surgery items people will be waiting for? People hear 'elective surgery', but if you are not a doctor you do not actually know what that means.

Prof. Greenaway : Understood, and it is a very good question. If somebody has arthritis and has, for example, crippling pain and has been assessed and needs a joint replacement, then—because, despite its effect on the quality of that person's life, it will not shorten that person's life if they do not have the operation within the next six months or 12 months—that is the sort of operation that would be deferred. Somebody who has carpal tunnel syndrome, where the median nerve at the wrist is compressed by a band of fibrous tissue that needs to be removed or released, will get weakness and tingling and very unsettling symptoms in their hands, for example. But that is not going to shorten their life so, again, they would be put on the back burner. So it is operations that can be deferred without necessarily having an immediate impact on the longevity of a person, although it certainly has major implications with respect to the quality of that person's life.

The other thing to say is that it has reached such a point, certainly in Tasmania, that the waiting time for procedures that need to be done acutely—for example, colonoscopies that need to be done to investigate somebody with possible blood loss from the gastrointestinal tract, which might indicate a colon cancer—are excessive, and we are not dealing with them in an appropriate time. These procedures include a number of different procedures but, certainly, the immediate effect of so-called elective surgery is to improve the quality of an individual's life, though it may not lengthen it. They are the procedures that tend to be pushed back when you have to deal with emergency admissions and acute present patients.

CHAIR: In short, because the funding cuts of $57 billion that happened in the 2014 budget have started to hit, the impact is that the state governments, particularly here in Tasmania, are pulling back on surgery for testing things like bowel cancer, which is considered an elective surgery when it is only a test or an investigation, isn't it?

Prof. Greenaway : It is a procedure that we have different categories as to the appropriate time frames and these are standardised within which these procedures should be done. I mentioned already that Tasmania performs very poorly in assessing or dealing with these cases in the appropriate time frames, and the reason for that is we do not have the capacity. It is not a question of inefficiency. If you look at the data it is a question of capacity. Senator Lambie already made the point about the number of public beds that Tasmania lacks. But it is not just the beds that we lack, we do not have the nursing staff to look after patients in those beds. We do not have, if you like, capacity to absorb the Commonwealth shortfall. When that happens, and given the reliance on the public hospital system in Tasmania, what gets pushed back are the elective procedures and we deal with the acute presentation.

I think your initial reference was to Campbelltown in the western suburbs of Sydney. I am well aware of their situation. It is exactly the same as it is in Tasmania. Over the winter period we are not expecting much in the way of elective surgery to be done here because we will be full of people with complicated presentations—heart and lung disease from influenza, the flu season, and dealing with the acute presentations rather than dealing with the elective surgery waiting list et cetera.

CHAIR: What we are seeing on this government's watch is barely enough money to really keep the emergency departments open and not enough money to do the surgery like hysterectomies, cystoscopies and eye surgery that people need. All of that is on the, 'Hold on, we can't afford to do that anymore. We're just looking after the emergencies.' Is that what is going on in Tasmania?

Prof. Greenaway : Yes, it is. Obviously, I have mentioned that the government is addressing at the minute the elective surgery waiting list with some additional funding by outsourcing—this is in response to Senator Lambie's question—the private system, specifically in Melbourne—

CHAIR: What we are really seeing is the privatising of health in Tasmania?

Prof. Greenaway : That is another specific issue: is this going to be an approach of government to this problem long term or is this just one-off money that is put specifically to address the acute problems? As I have said, it is a short-term fix. What we would prefer would be some additional resourcing of the public system so that we can deal with these issues in the future, because the waiting lists are never going to go away. They are always going to be there, particularly in places like Tasmania and South Australia where we have an older, poorer population who are more dependent on the public system for their health care.

CHAIR: It is true that if you have an elective surgery need to have a test for cancer, if that is delayed ultimately that might end up being a very acute problem—in fact, an unresolvable one in the end.

Prof. Greenaway : Yes, you are quite right. The reason that we categorise patients and that under guidelines there are times within which these patients must be seen is specifically for that reason. With category A patients, or patients that need to be seen within a particular time frame, the concern is that if they are not their condition will worsen and potentially threaten their lives.

CHAIR: Are category A patients in Tasmania currently waiting longer than they should be?

Prof. Greenaway : That is in all categories of the AMA's public hospital report card. The waiting times for various categories do vary. I would need to get those figures from the Department of Health and Human Services. I cannot give you the current situation except to say that in certain areas, such as the colonoscopy issue that I made mention of previously, it is the case that we are not meeting the current guidelines for patients who should be seen promptly.

CHAIR: That will be of great concern to the people. We are here in the north-west. I understand you are in Hobart, Professor Greenaway. Are there particularly significant problems for the north-west that are not being addressed?

Prof. Greenaway : That has always been a concern. The north-west historically has relied on a locum medical force specifically to look after their health needs. It is not a model that the AMA supports, because it does not encourage a specialist workforce to stay and become part of the community. The north-west traditionally has high rates of chronic disease, including cardiovascular disease. The reason the AMA supported the government principles of role delineation white paper was the notion that people, specifically in the north-west, could get access to specialist care more promptly. It is not a case of moving cardiothoracic surgery, for example, to the Mersey. It is a case of making sure that anybody who lives in the north-west can get the same, prompt, appropriate treatment as somebody who lives in, for example, Battery Point down in Hobart. So it is equal access that is the important think there. It is true that the north-west of Tasmania, particularly, has not been well heard by the health system previously. It is a focus of the white paper that the AMA supported, was that the north-west had improved access to the specialists to meet people's needs.

CHAIR: So any of the problems that you have described for the committee here today are worse in the north-west?

Prof. Greenaway : Yes, would be my answer to that.

CHAIR: Thank you very much for you evidence today, Professor Greenaway, and thank you for staying for a little bit longer with us.

Could I ask you on notice to provide us with not a fully comprehensive list but an indicative list of the sorts of surgeries that are considered elective that you describe as category A that are required to be responded to in a timely way that would impact people and have them coming through the hospital into the emergency department in a much worse state than if they got treatment at the elective surgery stage.

Prof. Greenaway : Certainly, I can do that.

CHAIR: Thank you very much.