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COMMUNITY AFFAIRS REFERENCES COMMITTEE
Public hospital funding
- Parl No.
- Committee Name
COMMUNITY AFFAIRS REFERENCES COMMITTEE
Senator CHRIS EVANS
Public hospital funding
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COMMUNITY AFFAIRS REFERENCES COMMITTEE
(SENATE-Thursday, 23 March 2000)
- Committee front matter
- Committee witnesses
Senator CHRIS EVANS
- Committee witnesses
Senator CHRIS EVANS
- Committee witnesses
Senator CHRIS EVANS
- Committee witnesses
Senator CHRIS EVANS
- Committee witnesses
Senator CHRIS EVANS
- Committee witnesses
Senator CHRIS EVANS
- Committee witnesses
Senator CHRIS EVANS
Content WindowCOMMUNITY AFFAIRS REFERENCES COMMITTEE - 23/03/2000 - Public hospital funding
CHAIR —I welcome representatives from the Australian Nursing Federation. The committee prefers all evidence to be given in public but should you wish to give any evidence in camera you may ask to do so and we will give consideration to your request. The committee has before it your submissions numbers 39 and 88. Do you wish to make any alterations to those submissions?
Ms Iliffe —No, thank you.
CHAIR —I ask you to make a brief opening statement and then field questions from senators.
Ms Iliffe —I will be making a brief opening statement. Belinda Morieson from the Victorian branch of the ANF will also be making a brief opening statement and then we will be very pleased to take questions on our submission. As background, the ANF is the Australian Nursing Federation. It is a national union for nurses in Australia and the largest professional nursing organisation in Australia. We cover all types of nurses: registered, enrolled, assistants in nursing and all specialist areas and classifications from directors of nursing to assistants in nursing, mental health nurses, remote area nurses, emergency nurses, midwives, et cetera. A number of state branches of the federation have put in individual submissions to the Senate inquiry and given evidence on the practical effects of funding policies on the workplace and the work force in their states and territories. I commend their submissions to the inquiry.
In my role as federal secretary of the ANF I want to give you a very brief global picture of how our members are telling us the funding arrangements are affecting them in their work. Firstly, I would like to say ANF as an organisation has a very strong commitment to the maintenance of our public health system as a universal access scheme, as centres of excellence, as the facilities which establish and maintain standards and which are open to public scrutiny. ANF has members in both the public and private sectors. We are comfortable with a health system which provides choice. However, it is our view that the private sector has a complementary role to the public sector and that it is the public health services which should be given government priority. We have been very critical of the enormous amounts of public money being provided for private health insurance rebates when the public system is, in our observation, not being provided with the funding that it needs to provide the services that consumers now expect and need. The private health insurance rebates do not provide any improvement in health outcomes. The same amount of money spent in the public sector would alleviate all of the current funding issues.
I want to briefly mention some of the effects on nurses that have been reported to us. First of all, there are the bed closures which are driven by a cost imperative rather than a demand imperative, and the shorter stays in hospitals which result in greater turnover of people requiring more complex care needs. The effect on nurses is increased workloads, no down time, greater stress with admissions and discharges, let alone more complex care requiring greater alertness and vigilance. Data from the Australian Institute of Health and Welfare Nursing Labour Force report shows that between 1995-96 and 1997-98 patient numbers in public hospitals increased by five per cent and, at the same time, the numbers of nursing full-time equivalents decreased by 2.9 per cent. During this time, separations per full-time equivalent nurse increased by 2.8 per cent and patient days per full-time equivalent nurse increased by 9.3 per cent. So, as you can see, there is increasing stress on nurses in the hospital system.
Nurses are frequently being required to provide care with inadequate material resources and in situations where they are breaching their own professional standards and duty of care. I give as an example people waiting or being treated on trolleys in corridors because there are no beds available. This is not the kind of environment where nurses are happy to provide care, yet they are often the ones to bear the brunt of consumer anger and dissatisfaction. This leads to low staff morale and more nurses leaving the system.
The discharge of people requiring more complex care has put a strain on community resources and our community nurses tell us that their services are unable to meet those demands. This is resulting in poorer health outcomes for people and placing a greater burden on families to provide the care. The issue is not the desirability or otherwise of early discharge, but the inadequacy of community resources for appropriate follow-up. Nurses are often placed in a situation where, ethically, they do not want to discharge people because they know they will not be able to access community care and they are not yet ready for discharge. However, pressure is being placed on them to discharge as the bed is required for a more acute admission.
Staffing levels are being reduced, again for a cost imperative, and this increases stress and the incidence of occupational injury. We have rising occupational injury rates for nurses, as reported by WorkCover reports and confirmed by a survey of health facilities in South Australia conducted by our South Australian branch of the federation. A recent survey of 2,000 nurses conducted by ACIRRT—the Australian Centre for Industrial Relations, Research and Training—for the Victorian branch of the federation, found that 56 per cent of those nurses considered that the nurse-patient ratios were a workplace problem and that 65 per cent worked unpaid overtime, such as working through meal breaks or extending their shift to finish their work. It was estimated that nurses' unpaid labour was contributing the equivalent of 300 to 450 full-time nursing positions per week. Eighty-seven per cent of the 2,000 nurses reported feeling stressed.
Increasing numbers of nurses are leaving the occupation or choosing part-time or casual work so that they can control their workloads. This puts an even greater strain on those who choose to work full time as they are constantly orienting new staff members unfamiliar with the environment or picking up workloads for new staff who are unable to perform high-level functions.
Among the other issues relating to cost are that nurses are unable to access study leave, not only because of cost but also because of the staffing levels. This means that they are unable to access further education or retain their skill levels. Hospitals are no longer offering specialist clinical education. This has led to a shortage of specialist nurses in many areas—paediatrics, neonatal intensive care, emergency department, critical care, operating room and midwifery, to name just a few. These costs are now borne by the higher education sector and the individual nurse. Hospitals are also opting out of enrolled nurse training. This cost is being offset to the VET sector, including private providers and the Commonwealth government through traineeships. Nurses also question the use of high cost technology when funding for basic care is not available. There is no quality assurance system which limits the use of technology to that which clearly demonstrates positive health outcomes.
Another issue for nurses is that the current arrangement where the Commonwealth has responsibility for one part of the health work force, predominantly doctors, and the states and territories have responsibility for most of the others, including nurses, has led to a situation where there seems to be unlimited funding for doctors and zero funding for anyone else. Two recent examples are the amount of money allocated to incentives for medicine in the last Commonwealth budget—$45 million for doctor incentives and zero million for nursing incentives—and the incentives being provided to attract and retain doctors in rural areas. This is leading to a great deal of unhappiness in rural areas where doctors who have been there for a very short space of time received, just before Christmas, thousands of dollars as a bonus when nurses and other health workers who had been there for many years holding up the system were completely ignored. People living in rural areas would also benefit from access to podiatrists, dietitians, psychologists and speech pathologists but, because that health work force is state funded, we are unable to obtain any funding to provide them.
I want to briefly mention a number of cost shifting areas that are of concern to nurses. We see not only cost shifting between different levels of government but also cost shifting to consumers. Scripts are provided to consumers when they are discharged rather than medications being provided and consumers have to provide their own dressings or aids when they are discharged and community services attend them. Consumers are required to have their pre-admission work-ups done by private services, whereas previously they had them done by in-patient services. There is cost shifting in emergency departments where people are refused treatment and referred back to their general practitioners and cost shifting in outpatient departments when people are referred to their general practitioners for referral to a private specialist medical practitioner or given a referral directly from the outpatient's department rather than receiving treatment there. Most of these things affect low to middle income earners. They are the ones who are reporting to us that they are feeling the most strain. Cost shifting occurs all along the line. Community services cost shift to HACC—Home and Community Care—providers and they cost shift to families and carers because they cannot afford to provide the care.
In rural areas, there is often no salaried doctor attached to the health services so the system must rely on general practitioners or visiting medical specialists. There is no incentive, in our view, for state and territory health services to employ salaried doctors as this would incur a cost for them. This places a greater burden on nurses and the general practitioners in the rural setting. In other settings, state government funded aged care facilities are being transferred to the private sector. Older people are also caught in the middle of the debate about who should care for them when they require acute care. Should community resources be brought into them, which is a cost borne by the state governments, or should they be transferred to public hospitals? The hospitals are also anxious to discharge them back to the aged care facilities as soon as possible and that cost is then offset against the Commonwealth.
All in all, ANF does not see it as our role to make recommendations about the funding arrangements between the different levels of government. We do consider, however, that the funding must be sorted out so that the health work force can do the job they want to do and are trained to do. Whatever system of funding is determined, it should look at health holistically. It needs to be considered within the overall context of health care provision across different sectors and jurisdictions. The funding arrangements for public hospitals must be considered within the entire health system. Thank you.
CHAIR —Thank you very much. Did you wish to make a comment, Ms Morieson?
Ms Morieson —I would like to make a brief comment, if I may. Essentially, it is to emphasise two aspects that Jill has mentioned. One is the workloads issue, and in this state we are suffering from an exodus of nurses from the system to such a degree that one has to question whether or not the health system, as we know it, is going to survive over the next few years in this state unless that is addressed. The workload problems are essentially caused by shortages in the budget. There are not enough staff, and whereas there might be money for high-tech equipment such as scanners, there is very rarely enough money at the ward level for things such as simple dressings and a sufficient amount of clean linen, et cetera.
Nurses do not understand the way the health system is funded. They read the newspapers where the federal government says they have increased the funding and the states have taken the funding out. Then you read in the newspapers the reverse comment made by the state governments that say it is actually the Commonwealth that has taken the money out and they have increased it. What the nurses in this state, I believe, would like to see is a transparent system of funding whereby there is a fixed percentage of federal and state moneys put in on a per capita basis, taking into account the rural-metro mix, ethnicity and other such factors, and that this sum of money, based on per capita, would then be increased on an annual basis with the CPI. Until you have a transparent system of funding and nurses can see that what they are getting is the same as nurses in other states, I can see that the public health system in this state and public hospitals are going to continue on a downhill slide. I will leave my comments at that.
CHAIR —Thank you. Ms Gilmore?
Ms Gilmore —No.
Senator TCHEN —Ms Morieson, you said that the funding should be transparent and that it should be based on population. Isn't that how the current Australian health care agreements base their funding? At least, the Commonwealth's proportion of it is on a population basis.
Ms Morieson —Yes, but the problem as I see it is that it is not a fixed percentage of state and Commonwealth—
—Within the states.
Ms Morieson —and it is not transparent, because you still have the cost shifting issue.
Senator TCHEN —As far as the Commonwealth is concerned, all that the Commonwealth can do is provide the funding on a needs basis, which is reflected in the population base. Once it gets to the state, it is up to the state how it manages it, and it is up to the state to match the funding. Part of the problem that we have found is that the Commonwealth has been putting in money and the state has been pulling it out.
Ms Morieson —Yes, and if I go to the state, the state will tell me the reverse. That, as I see it, is the issue: there is not a clear understanding by health workers of where the funding problems lie. I understand what you are saying in terms of the Commonwealth responsibility, but there are many areas where you can reach agreement between state and Commonwealth.
Senator TCHEN —The first round of the Australian Health Care Agreement provides for a 25 per cent real increase over five years by way of Commonwealth funding—about 20 per cent in the first year. Are you aware of that?
Ms Morieson —I am aware that that is said, but I am saying to you that the health employees do not, at this point, believe that, with respect to the way the funding is occurring, they are being serviced either by a state or by the Commonwealth. There may well be an announcement in the newspaper that there is going to be an increase of 25 per cent over four years.
Senator TCHEN —It is in the budget papers as well.
Ms Morieson —I understand that, but I am trying to explain to you the effect on the employees at the bedside of the fact that it is not clear where the responsibilities lie and what the percentage responsibilities are.
Senator TCHEN —So it is not the amount of Commonwealth contribution that you are concerned about; you are happy with that.
Ms Morieson —I did not say I was happy; I am not happy with any contributions, state or Commonwealth. What I am saying to you is that, at this point, the nurses in this state, at any rate, would say, `A curse on both your houses.'
Senator TCHEN —But the fact is that the Commonwealth has put in a 20 per cent increase in the first year, 1998-99, and an average further increase of about six per cent per year for the next four years.
Ms Morieson —If what you say is correct, you are not getting any credit for it.
Senator TCHEN —Your concern is about what happens to the money once it gets into the system; that is what your profession is unhappy about?
—My members are unhappy about the fact that there is an inadequate amount of money, and they are not clear about the reason for that inadequacy. They are looking for a transparent system that says, hypothetically, that the Commonwealth will give $10 and the states will give $10 per head of population for public hospital care. That does not exist at the moment.
Senator TCHEN —If the transparency exists, then you are not too concerned about the amount—or are you still interested in that?
Ms Morieson —Of course I am concerned about the amount. The amount at the moment is inadequate.
Senator TCHEN —Basically, what you are saying is that, firstly, transparency and, secondly, the amount—or perhaps the other way around—are linked directly to quality of patient care?
Ms Morieson —It is inevitable, isn't it? At the end of the day, the amount of money going into the system is going to affect the outcome.
Senator KNOWLES —How does nurses' preoccupation with where the money is actually coming from affect patient care? That is the nexus.
Ms Morieson —No, what I am saying is that nurses in Victoria, at this point, cannot look after the patients properly because of the budget restrictions. Nurses do not understand—and I would suggest they are not unique in the community—where the fault lies, because you read in the paper—
Senator CHRIS EVANS —Actually, Ms Morieson, that is one of the reasons for this inquiry.
Senator LEES —We do not know either. That is what we are trying to find out.
Senator CHRIS EVANS —I do not know why you feel pressured about this. One of the terms of reference of this inquiry is to come to grips with that very problem.
Senator TCHEN —I understand that. It is just that Ms Morieson was trying to draw the connection between nurses knowing where the money comes from and their ability to give care—
Ms Morieson —No.
Senator TCHEN —but I would have thought the amount is important. If you are given adequate funding you do not really care where it comes from, do you?
Ms Morieson —I do not care. At the end of the day in the debate and the argument between the federal and state governments, if it finishes up that you give $20 and the states give $2 on the proviso that $22 per head of population is sufficient, that is fine by me.
—Okay, but you have no argument if I say to you that federal funding has increased 20 per cent in 1998-99 and that is not matched by a state increase—
Senator LEES —We might have problems.
Senator TCHEN —and there is a budgeted increase by approximately six per cent per year for the next five years—
Senator CHRIS EVANS —Senator, are you claiming that federal funding increased by 20 per cent last financial year?
Senator TCHEN —No, 1998-99 when the new agreement came in. The Commonwealth's contribution went up about 20 per cent.
Senator CHRIS EVANS —Over what period? I was not clear what you were saying there either.
Senator TCHEN —For example, the New South Wales government received $1.6 billion in 1997-98 and they received $1.9 billion in 1998-99—that is according to their own figures. That is a 20 per cent increase, and I think it is the same with other states.
Senator LEES —But you have to look at the other grants, as well, which is what this inquiry is doing. It is not just Medicare.
Senator TCHEN —That is the total grant.
CHAIR —Point 3 on 1.6?
Senator TCHEN —Yes.
Senator CHRIS EVANS —I do not think that Dr Wooldridge claims a 20 per cent increase in federal funding.
Senator TCHEN —I am not going by the minister's claim; I am going on the figures provided in the New South Wales paper. Certainly there is a 25 per cent increase in real terms budgeted between 1997-98 to 2002-2003—that is from the Commonwealth's point of view.
Ms Morieson —All I can say is that I find that difficult to believe and I would have to look at the data that you are—
Senator TCHEN —That is the data.
Ms Morieson —I am happy to look at where that data is coming from and the specifics of it.
—All right. Let me get onto other figures. Ms Iliffe, you raise some objection about the Commonwealth's 30 per cent rebate for private health insurance. From your understanding, what is the government's objective related to that 30 per cent rebate? It seemed to me that what you were saying is that the government is only interested in giving the money to the private health insurance companies. Can you tell me what you really think the government's objective is?
Ms Iliffe —I do not particularly want to get into a debate about private health insurance. That was not the point I was making. The point I was making is that there is a considerable amount of money being put into private health insurance rebates where, if an equivalent amount of money were put into the public hospital system, it would alleviate all of the concerns that nurses are raising with us about the inadequacies of the public hospital system. That is the point that I am making. I am not really interested in getting into a debate about the merits or otherwise of the private health insurance rebate.
Senator TCHEN —But isn't it important that the public hospital system is part of the national health system which is not the only system? You say they are complementary.
Ms Iliffe —I did not say that in my comments. I said that the federation is quite comfortable with a health system which provides choice with a private-public sector mix. However, we are observing a tremendous amount of public money being put into the private system and not an equivalent amount of money being put into the public system.
Senator TCHEN —But the money is not just going into the private system because some of the money comes back into the public system, doesn't it? The insurance system also funds the public system.
Ms Iliffe —I do not quite follow your argument, I am afraid, but, regardless of that, we are not seeing the same amount of money being spent in the public system as we are seeing spent on private health insurance rebates. Even a fraction of that money would alleviate the concerns that nurses have at the workplace in being able to provide the care they know they should be providing.
Senator TCHEN —I put it to you that your view, in representing nurses, is focusing only on the public system instead of looking at the health system as a whole. For the 30 per cent rebate, you are looking at 30 per cent of the money going back to the taxpayer who has taken out health insurance. Let me put it to you that that 30 per cent guarantees that 70 per cent of the payment is actually coming into the health system as a whole. Let us say that there is $2 billion going back by way of the rebate—which is too high; that is the projected figure for two years down the track—that represents over $5 billion coming into the health system. If you do not put in that $2 billion, you have to find, nationally, another $5[half ] billion to go into the health system as a whole.
Ms Iliffe —I suppose I am operating from a much simpler base than you are, Senator. My position is that the funding that has been provided for health insurance rebates has given very little gain as far as uptake of private health insurance is concerned. While it has given some gain, it has given very little gain.
Senator TCHEN —It is early days yet.
—Maybe it is. However, we still see large numbers of privately insured people using the public health system. The point that I am making is that an equivalent amount of money spent in the public system—even half of the equivalent amount of money spent in the public system—would address many of the concerns that are being raised with us. Nurses see that there is a great inequity in the way that public moneys are being spent.
Senator TCHEN —I am sorry to be jumping around a bit, but because of some of the headings you have put out I do not want to concentrate on just one point. With respect to cost shifting, I noticed in your written submission you said that the state branch would provide evidence on cost shifting. The state branch actually did not. You did not mention too many factual instances of cost shifting.
Senator CHRIS EVANS —The Queensland Nurses Union yesterday provided a great deal of evidence.
Ms Iliffe —And the South Australian branch.
Senator TCHEN —Yes, I know.
Senator CHRIS EVANS —I do not think she was referring just to the Victorian branch.
CHAIR —Ms Iliffe also gave us a long list, I thought. Did I not hear you?
Ms Iliffe —Yes.
Senator TCHEN —It is just that, as a Victorian senator, I have been told that Victoria is the cost shifting capital of Australia and I thought I would get more evidence from Victoria.
Ms Iliffe —No. The state branches that we were referring to are our state branches that—
Senator TCHEN —Other states.
Ms Iliffe —Yes. We have branches in all states.
Senator TCHEN —There is nothing from Victoria?
Ms Morieson —No, I have not put in anything about cost shifting.
Senator TCHEN —That is a bit disappointing. My final question is: you have put a lot of emphasis on the nurses' view of the public system. What about your members who work in the private system?
—As I said in my opening statement, we cover nurses in both the public and the private sector. We are very comfortable with that public-private mix. The two points that I have made this morning are that public hospitals, from our members' perspective, are being deprived of funding. Our priority is a public system which is well funded, which can remain as a centre of excellence, research and teaching and provide quality care for all Australians, whether or not they are privately insured.
Senator TCHEN —In that case, I will close my questioning on this point: going back to your concern about the private health insurance rebate, if I say to you that the government's primary objective in providing a rebate is to give people affordable choice between the public and private systems, you do not have a problem with that?
Ms Iliffe —No, I do not have a problem with that.
Senator LEES —I would like to go back to the pressures on the public system as a result of the government putting $2 billion into the pockets of people with private health insurance. Looking through all the evidence before this committee, the largest amount that anyone has suggested is filtering through to the public system is somewhere between $400 million and $500 million of that $2 billion a year, and even that is hypothetical at this point in time. Because of the increased pressure on the public system, even that is being watered down.
To pick up Senator Tchen's point about the increasing percentage from the federal government, the states were so unhappy about that being so far behind inflation over five years that this was what the arbiter was called in to fix, and then the Commonwealth government would not accept the arbiter's suggestion that it needed to be inflation plus 0.5 per cent to give you some relief of pressure. What I would like to ask you specifically on the pressure issue is: how is it actually manifesting itself on the ward? Looking back, say, three or five years, what sort of changes are you seeing on a day-by-day, shift-by-shift basis in terms of stresses for nurses themselves?
Ms Morieson —The first thing is a significant reduction in the number of nurses per patient whilst, at the same time, the acuity of the patient has increased. Whereas the average patient five years ago might have required six hours nursing in a 24-hour period, they now require 10. That is because of the decreased length of stay. So that is one thing. Certainly in this state there is a difficulty in accessing sufficient amounts of equipment—and I am talking about simple equipment: IV stands and pumps, dressings, clean linen, very basic stuff.
Senator LEES —Aren't they in store? Don't they just go down to store and get them?
Ms Morieson —No, because hospitals have started `just in time'—maybe not to the degree that they do at the Toyota factory, but certainly you do not have the amount of stock you used to have.
Senator CHRIS EVANS —This is a new management technique where you only have it available just in time?
Ms Morieson —Yes, it is called efficiencies, best practice.
Ms Gilmore —It is a minimum and a maximum level of supply once you hit the minimum point. It happens with linen as well as other—
—Is that used in acute care as well?
Ms Gilmore —Absolutely.
Senator CHRIS EVANS —And you are saying it is not getting there in time?
Ms Morieson —It is not getting there in time, and very often—
Ms Gilmore —It does not get there at all.
Ms Morieson —We have had a situation where wound management nurses at a major metropolitan Melbourne hospital thought that somebody with a large and gaping wound needed a certain dressing that cost $26 and that had to be changed four times a day, and the order came down that they were no longer allowed to order those sorts of dressings. That is the sort of thing I am talking about, involving very basic bits of equipment, that causes nurses distress because they cannot do the job properly.
The other thing that has happened with the pressure on the budgets is that the support staff have been taken away, whether we are talking about cleaners or physiotherapists. It is traditional in hospitals that it is nurses that are there 24 hours a day, seven days a week, so if there is no longer a physio on the evening shift it is the nurses who do it. We have an oncology ward where the nurses are cleaning the toilets when they are on night duty because they are not being cleaned anymore on a daily basis. We are talking about an oncology unit. It sounds emotive, but it is fact. That is happening in every ward across every public hospital.
Senator LEES —Do you see any way of reducing the demand on the nursing staff, particularly in our acute public hospitals?
Ms Morieson —You mean in the future the increasing workload demand?
Senator LEES —Yes. We are looking at the pressure on you. Obviously more money would help. Is there any other way we could see, other than an increase in funding, to reduce that pressure?
Ms Morieson —I do not believe so because there is an increased demand for increasingly expensive things to take place. When I was in an intensive care unit 20 years ago, somebody over 75 would have a tough time getting in. They are now 85 and they are having complicated and major surgery. I do not see the community accepting it—I do not see politicians suddenly saying, `Let's go back and we will not take anybody over 75 into intensive care units.' So the demand is going to increase.
Senator CHRIS EVANS —My view on that changes as I get closer to it. When I was younger I had a much harder line on that stuff.
Ms Iliffe —Senator Evans, before you start your questions, I would like to ask Victoria Gilmore, who has recently come from the clinical coalface, to make a comment in response to Senator Lees's question on the effect that the funding is having.
—I think the biggest change is actually, as Belinda commented, that patients are going home much sooner and the complexity of discharging patients out of the hospital is going up and up. It is not the old days of saying you are ready to go and just waving them off. At the same time you have got someone waiting in emergency to actually come into that bed. I come from a paediatric medical background where the pressure on beds is enormous. Basically, the nurses on the ward are often managing two patients at a time. They are discharging at the same time as they are admitting and it is a huge pressure on the nurses. It is almost a doubling of workload as well as the other stresses commented on by Belinda and Jill.
Senator CHRIS EVANS —I wanted to ask you about community nursing and the interface with hospitals because one of the issues that is coming up all the time for us concerns the community sector and the GPs et cetera not connecting with the public hospitals. There just does not seem to be any integrated system at all. We have also concerns raised about how other community programs like HACC are working. What is your perspective of the problems in the system about sharing information and making sure there is coordinated care basically on discharge and that sort of thing?
Ms Iliffe —I think that one of the major difficulties is that there is so much pressure on the system that people do not have time to do the sorts of things that they would like to do, and coordinating care is one of them. From what our members have to say the first problem is discharging people who they do not think are ready to be discharged because there is pressure on the bed. The second is that they go to a community sector that is under-resourced, so there are waiting lists now for community nursing services. Just a few years ago, there were not waiting lists. So you are having to prioritise who you provide service to. Then some of those care needs are transferred to HACC services because the community nursing services cannot cope with them. HACC services cannot cope with them so they are transferring them to carers and families are having to look after them which impacts of course mainly on women who may have to take time off work if they are working to look after family members.
There certainly is the potential for better coordination. In some areas they have developed an assessment system, which is a single assessment system, so that all of the people involved actually know there is a discharge plan. But in all honesty in the last 12 months to 18 months discharge planning has become almost impossible because of the faster throughput. As Victoria said, you are discharging people at the same time as you are admitting people. There is too much pressure to be able to do a proper discharge plan and make all of the referrals that you need to make and involve all of the people that you need to involve. We used to be able to have case conferences where the GP would come in and you would actually plan that care and everyone would be involved. The pressures are so great now that you just do not have time. That is a luxury.
Senator CHRIS EVANS —Same day surgery that does not work.
Ms Iliffe —That is right. I do not know if Belinda wants to make a comment from the Victorian perspective.
—Certainly, in Victoria, we used to have nurses that were case coordinators. We used to have nurses who were admission and discharge nurses. We do not have them anymore. They have all had to go because the directors of nursing have been put in the position with their budgets of deciding whether to make redundant a couple of grade 2 nurses at the bedside or make redundant the more senior nurses in what are not essential bedside positions. Those sorts of nurses have disappeared out of the system.
Senator CHRIS EVANS —I had better ask you about the FBT, particularly in Victoria, because I asked the state government about that. What is the ANF's view about what happens on 1 April? How does it affect your members who have salary packages?
Ms Morieson —We have salary packaging agreements throughout the public sector and also in every private and not-for-profit hospital. Because I guess we have a fundamental dilemma philosophically about salary packaging, which is reducing the tax pool at the same time as we are asking for more money to go into health, we have kept our salary packaging agreements so that the maximum they can salary package is $30,000. There has been a range of pick-up. The other thing that has happened in this state is an increasing number of full-time nurses have dropped back to part-time because they cannot cope with the full-time stresses anymore and, therefore, their income drops below where salary packaging is of much benefit. But, having said that, there are a substantial number of nurses who, if the legislation as proposed goes through on 1 April, will suffer a significant drop in their take-home pay.
Senator CHRIS EVANS —So $30,000 is what the ANF has refused to negotiate beyond. Is that right?
Ms Morieson —That is right.
Senator CHRIS EVANS —Are you aware of nurses who have negotiated individual agreements beyond that level?
Ms Morieson —I would expect there would be some individual directors of nursing in the major hospitals who may have done that.
Senator CHRIS EVANS —But $30,000 takes you well above the current capping proposal.
Ms Morieson —That is right.
Senator CHRIS EVANS —What, from your understanding, happens to those people on 1 April?
Ms Morieson —Their take-home pay drops. The agreements were that if there was a change in legislation, we could not hold the employer responsible; the employee can package approximately $9,000, in effect.
Senator CHRIS EVANS —Are you in formal renegotiation of those things? It seems to me that the FBT is payable by the employer, so what is happening if they got their mortgage or their ANF fees paid or whatever? What happens in a process sense on 1 April? Do you think they just deduct the cost of the FBT out of their salary?
—No, I think that will all come out of salary packaging arrangements. It is not something that we have been negotiating with the employers. I understand the doctors have and they have reached some satisfactory arrangements, as they tend to do. If you were to ask me what nurses would like, they would like the ability to salary package up to $30,000 and put a cap on it, but not such a low cap as the one that is being considered.
Senator CHRIS EVANS —You made an interesting point in your submission about the Commonwealth seeming to have taken responsibility for doctors' recruitment and the states having responsibility for nurses and other health professionals. I guess it comes back to the state-Commonwealth funding argument, which is partly what this inquiry is supposed to be getting to the bottom of—to better explain to everybody how we might better fund it so that there is more transparency. In fairness to the government, I understood they had a large meeting and an initiative about nursing recruitment in Canberra a few months ago.
Ms Iliffe —Yes. Last September there was a two-day forum held to look at nursing work force issues. The nursing profession quite clearly was saying that nursing is not just a state and territory responsibility; there are national implications. We have a national nursing shortage. We are recruiting fewer people into nursing undergraduate courses. We are recruiting fewer people into postgraduate specialty areas and the whole of the Australian population is going to suffer if, in three or five years time, we do not have enough nurses.
Unfortunately, Senator Evans, there were two unanimous recommendations from that forum—which is rather unusual in a large group of any sort of people, but certainly a large group of nurses. One was for the establishment of a national nursing work force committee and the other was for the appointment of a chief nurse at the Commonwealth level who could speak on behalf of nursing directly to the Commonwealth government. Those recommendations went to AHMAC. AHMAC has asked for a small subcommittee to present some options to their June meeting as to how those recommendations might be implemented. But I would have to say that the nursing profession is feeling quite disenchanted by the length of time that has taken and the lack of confidence that we are getting from the whole process, when these issues are really quite urgent.
Senator KNOWLES —I want to come to the issue of privatisation. I notice, Ms Morieson, that in your submission you say:
Privately run public health removes the guarantee that the public's particular interests will be protected in regard to diversity, cost, quality, access, equity and community responsibility.
How long has this hospital been operating?
Ms Morieson —St Vincent's?
Senator KNOWLES —Yes.
Ms Morieson —I would have thought 150 years or something like that.
—I thought it was about 107 years. I thought that during that entire time it was run by the Sisters of Charity.
Ms Morieson —It is a public hospital in the sense of getting public funding and public accountability. Perhaps if I explain the background to the comment made in our submission—
Senator KNOWLES —Just on this hospital, for example, is my understanding correct that this is operated by the Sisters of Charity, and has been for 107 years?
Ms Morieson —Yes, that is correct. But I think there is a difference between being run by a not-for-profit organisation and being run by a for-profit organisation. We have an example here in this state where the public hospital that was privatised in the Latrobe Valley has recently closed down services in an argument that they are not being funded adequately through the private-public agreement. The evidence for that statement is there in this state at this point in time.
Senator KNOWLES —But where is there a demonstration in this hospital, for example, that ownership has removed the guarantee to protect diversity, cost, quality, access, equity and community responsibility?
Ms Morieson —Perhaps we were not clear in our comment. It was the privatisation for profit, allowing a for-profit company to take over a public hospital and provide the services. That is where our concern lies. I should apologise to the Sisters of Charity if they have been swept up in that statement. It was not intended.
Senator KNOWLES —I just want to come to one final thing briefly. We had evidence—I think it was yesterday—from ANF in Queensland about retention rates in nursing. They gave the shocking example, I might say, that a lot of nurses were over 40. I said, `Oh, dear,' as if 40 were somehow on the wrong side.
Senator CHRIS EVANS —We all fell about the table.
CHAIR —Senator Evans also pointed out that the average age in the Senate—
Senator CHRIS EVANS —Was a lot higher.
Senator KNOWLES —We shook in our boots when we knew it was over 40 but we understand the point that they were making. I am asking: what are you doing, or what is being done generally in this state, to try to attract young men and women into the profession? Without them the system will undoubtedly collapse.
—It is an issue that I have been attempting to address with state government for some years. I am very pleased to say that the new government has taken up the issue and they have established a retention and recruitment committee that will be providing an interim report to the health minister in April and a final report in August. There are three subcommittees to that retention and recruitment committee. It is the recruitment subcommittee that has the job of specifically looking at how you attract young people. Two states, Western Australia and New South Wales, have recently run, as I understand it, fairly successful large advertising campaigns to attract young people into nursing.
Senator KNOWLES —When we say `successful' what sort of rate are we getting?
Ms Morieson —I do not know the details, I am sorry.
Senator KNOWLES —We are pressed for time. Are you aware of any of the public hospitals that have shut down services?
Ms Morieson —Yes.
Senator KNOWLES —Where and what services?
Ms Morieson —There has been a range of services. We have had 1,000 to 1,200 beds closed in this state over the past seven years. That clearly causes a reduction in services. We have a number of services that have been privatised, which is a form of cost shifting if you like, where we have had radiology, pathology and those sorts of services sold off by public hospitals to private companies. We have had a reduction in home visiting services in a number of public hospitals. We have a reduction in illness prevention programs that are run by hospitals. In nursing alone there are a number of areas like diabetes education, for example, that ran services for outpatients and in-patients, and those have closed down.
Senator KNOWLES —Thank you.
CHAIR —We have passed our time. I did want to ask many questions but in the interest of us all I am going to try to resist. But Senator Tchen would particularly like me to pick up on a point that has been raised by a lot of witnesses before the committee, the question of quality and outcome. In your submission you mentioned that a lot of the evidence or data that is collected is about process and not about outcome. I gather from your submission that you are interested to participate and, indeed, would like to see that change. Where is it at and how will it change? What are you doing about it?
Ms Iliffe —Certainly, in the submission from the federal office, we made the point that we would like to see some emphasis given to data collection on quality outcomes rather than on process. If you remember, it states that it would be good if the Australian Institute of Health and Welfare, in addition to what they are already collecting, could collect some information on outcomes. There is also a reference to the accreditation system that is being run by ACHS, and we support that sort of system that focuses not just on process but on outcomes as well.
—We have had a lot of evidence given to us about walls or gaps that people have to cross over in the system, from outside the hospital into the hospital, from hospital back out again and so on. I am also interested in the way you have presented it today—that the Commonwealth looks after the doctors and the states look after the nurses, which is very pungent and very much to the point. The other area that is interesting to us is information technology. We have had it put to us that in Australia we are about 25 years behind, having regard to where we might be. To what extent are your members involved in using IT on the ward and/or in data collecting?
Ms Iliffe —I will ask Belinda to comment on the metropolitan area, but with respect to the other branches, particularly Queensland, Western Australia and the Northern Territory—but not just those states and territories—the problem with IT is not having access to it. If there is IT in the facility, there is such a demand for it that the nurses do not get access or there is not any access at all. IT was one of the things that we raised with the federal government as being an area of improvement in rural health that would be worth their putting some funding into. They spend a huge amount of money on providing IT for general practitioners, whereas nurses in many rural areas cannot get access to any IT information at all, so they cannot communicate, they cannot update themselves, because there just is not the physical access. The other thing is that sometimes you cannot get access not just because of not having the technology on your desk, but because in some of the remote areas you cannot get it. It would be worth while making some effort in that regard. I do not know whether Belinda wants to make a comment.
CHAIR —In your brief closing comments, Ms Morieson, can you also refer in passing to IT within major metropolitan institutions. Are your patient health records on computer yet?
Ms Morieson —That is increasing, but it tends to be one screen at the sister's station. It is not at the end of the bed. It is very often a system that is put in without reference to nurses. It is very frequently put in with inadequate training. Because we have got such a high turnover of nurses, even if the training was okay when the bit of equipment was put in, six months down the track there is no nurse there that went through that training. Also, nurses view this as simply an additional workload that they do not perceive any benefit from, because that data goes down into records and they never know what happens to it, anyway. So I would have to say that, at this point in time, I think the experience with IT in the metropolitan hospitals has been unfortunate.
CHAIR —I want to thank you very much, and I hope I was not stopping you, Ms Gilmore, from saying something?
Ms Gilmore —No.
CHAIR —If there is something that you want to add to your submission, feel free to do so. If we need to contact you, I presume that would be acceptable. Thank you very much.
Proceedings suspended from 12.18 p.m. to 12.42 p.m.