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COMMUNITY AFFAIRS REFERENCES COMMITTEE - 23/03/2000 - Public hospital funding

CHAIR —Welcome. The committee prefers all evidence to be given in public but should you wish to give any of your evidence in camera you may ask to do so and the committee would give consideration to your request. The committee has before it your submission No. 23. Do you wish to make any alterations to the submission?

Mr Woodruff —No alterations, but we do have an additional document to table.

CHAIR —Thank you.

Mr Woodruff —This is our Report on the development of allied health indicators for intervention (IFI) and performance indicators (PI) project.

CHAIR —I will ask you now to make a brief opening statement and then we will field questions.

Mr Woodruff —Thank you for the opportunity to present. I would like to start by giving you a very brief overview of what the National Allied Health Casemix Committee is and what it does and then I will hand over to the two other witnesses to talk about specific issues. The National Allied Health Casemix Committee is the peak body representing the allied health professions in matters relating to casemix funding and outcome measures development and we have representation from 13 national bodies that allied health belong to. Each of the states and territories has an Allied Health Casemix Committee that belongs to our national collective. We also have representation from the Commonwealth Department of Health and Aged Care and the Health Professions Council of Australia. We operate from the RMIT University in Melbourne.

Our achievements in the short life that we have had over the past few years have been to coordinate the allied health voice in matters relating to health care particularly in reference to the Commonwealth. We have a close relationship with the Commonwealth Department of Health and Aged Care and act as advisers to the department. We have developed a national activity hierarchy that standardises the way that allied health professionals describe their inputs to the health care system. We have also developed a minimum data set that describes characteristics of the clients and patients that are treated and we are in the process of developing patient focused performance measures or outcome measures for those clients where allied health have a large role to play in their outcomes. We also act as the main education and resourcing body for allied health professionals when they deal with research and other matters relating to health care funding and we act as a national clearing house for activities that occur.

Very briefly, we want to talk mainly about some of the limitations to the advancement of allied health in their role in contributing to patient care, and I will ask both Davids to address those in detail. In summary the limitations are that we have a very low opportunity base to participate in broader health service management activities and discussions. Allied health are a significant work force within the hospital setting but it is uncommon for them to have representation in senior management level within hospitals so we have limited opportunities to express views and contribute to planning.

The other major concern we have is that there is a lack of available information technology infrastructure to collect and analyse activity that relates to patient outcome information. That limits our capacity to operate within a paradigm of evidence-based practice which we all strive to do. With that background in mind, I would like to hand over to David Rhodes to talk specifically about some of those issues.

Mr Rhodes —As Ian has indicated, our submission was largely around the infrastructure basis for allied health people to know what they are doing, what their business is, so they can actually feed into the debate in a more intelligent manner than anecdotal presentation. So the absence of an appropriate infrastructure limits the way in which we can assist you in forums like this and assist our local managements in looking at innovative service provision and so on because we do not actually have a solid base of information about what we are currently doing. That flows over into multidisciplinary team activities as well in the hospital setting, and also in other settings, because allied health is a key player in a whole range of interventions such as rehabilitation, oncology and so on, and the absence of our allied health data makes it much harder to provide information to focus the direction of where funding should be directed.

I guess we are putting the view that decision making about where funding goes is tiered through a multiple layer of decision making processes, many of which allied health do not have access to in terms of formulating approaches. We are very small numbers of people, very much focused and absorbed in clinical service provision, with usually only one person, if that, in each profession who can play a key management role within hospital organisations. Allied health has—and many managements are now recognising it—not benefited from some of the other opportunities that other components of the hospital service have in terms of attracting funds.

We have a large deficit in IT hardware infrastructure systems. Many allied health people do not have access to PCs, which provide both hospital based information in terms of diagnostics, clinical records and so on, and also mechanisms to keep track of what they are doing, and particularly to lead that into indicators and outcomes for patient care. We also do not have consistency in software applications that are available to us, and the adequacy and comprehensiveness of that software is highly questionable. As a result, we have difficulty in reporting what we do in a meaningful way to managers and to clinicians and a very limited way in terms of manipulating that data to suit the purpose that we are looking at at that time.

I guess a bigger issue, and it is one that affects other areas other than allied health— medical and nursing staff would relate to it as well—is that in the hospital setting we do not have sophisticated clinical management systems in many settings. Some hospitals do have some, others do not, but allied health generally is not participatory in those systems. And that is the objective, it is not just to collect data about what we do but to actually use data in forming our clinical decision making with clients and extracting our activity out of that.

As others may have said to you, there is an absence of nationally standardised classification systems about what we are doing in hospitals, particularly in ambulatory care settings. There is not one consistent way of looking at how we classify patients in that setting. So in terms of looking at funding implications and how that might flow into outpatient services and community based settings, it is very hard to actually pull that data together into any sort of meaningful and sensible format.

The implications for allied health are that we are somewhat stymied in terms of development of patient focused outcomes. There is a lot of energy spent wishing to do that, together with other health professionals, but without access to a suitable information system it is an additional burden, and also extremely limited in its capacity. We also have great difficulty in implementation of standard performance measures. As we were discussing with you in terms of reporting on performance to particular indicators, you really have to have a system to be able to produce the data to feed that back to whoever wishes to access it. Additionally for allied health, services are very much related to the local historical circumstances in terms of how much resource is given to allied health and to the success or otherwise of the local lobbying of allied health staff.

One of the objectives of allied health groups is to come up with some kind of benchmark that might indicate that, for such and such a community generally, the community needs access to X, Y, Z allied health services. We would be interested in working further towards that, not just for in-patient settings but for ambulatory care settings and community based settings where there is wild divergence around the country in terms of what is available. How we would like to use the information is to better analyse and manage not just our business but to contribute to the business of hospitals and community based services. I will give some examples of that. Continuum of care case coordination is extremely difficult without suitable systems to assist you, so we end up adding to the burden of patients and their carers in terms of reassessments, redoing diagnostic tests, et cetera, between the different phases; and so getting transfer of clinical information across the system, case planning, discharge and follow-up arrangements are problematic.

Another big issue is access to community based resources. Whilst this is focused on public hospital systems, for allied health there is an intrinsic link between community based service infrastructures and hospital based infrastructures. For example, if there is not a good community based system, then that work flows back into the hospital outpatient ambulatory settings which places additional burden on the hospital in terms of meeting that demand. It consequently impacts even more substantially on the distribution of funds within the hospital system. Also, as was discussed in the previous presentation, the diversity of funding mechanisms creates not only an administrative burden but a clinical burden. For allied health to stitch together a discharge care plan for a person might mean liaising, negotiating, badgering up to four or five different community based agencies to pull together a bit of respite care, a bit of home help, a bit of this and that, so that the person is actually able to be discharged home within an appropriate time frame rather than being retained in a public hospital setting waiting for those things to occur. The complexity of funding mechanisms certainly adds to that problem.

We also experience difficulties in terms of flow-on effects of things like provider number, provider status, for allied health professions. In some settings, public sector professions cannot access provider numbers. They might be providing services into, say, a private hospital. The private hospital cannot afford to charge the patient because it is not covered by the insurance company, so it then flows back to the hospital system to pick up that work.

There is also a lot of competition at the local level between hospital and community based services which is often detrimental to the joint outcome that both parties wish to achieve. There are lots of vicious cycles in terms of what happens for the allied health experience at the local level. Pressures are always on hospital expenditure. That can often lead to reductions both within the hospital and also in the community based sector, which then compounds the workload for allied health staff who then see growing waiting lists in outpatient settings, inability to respond in a timely way to clinical needs and the difficulty staff have with coping with that sort of thing.

Senator LEES —I am sorry to interrupt but, with cuts and cutbacks and efficiencies and all those things, is allied health often targeted as one of the primary sources of cost savings?

Mr Rhodes —On an annual cycle, yes, because of staff turnover. There is often the opportunistic saving that can be achieved by saying, `Okay, we have got this vacancy, we will not fill it at all or we won't fill it for a while.' That happens a lot. It can happen particularly in some forms of management where there is not a strong allied health valuing. It can also happen not in a targeted way but still impact on allied health. The most absurd example I heard this week was where an allied health service, which was 1FT, was required to cut by 10 per cent and they were wondering which limb to sever to make the saving. That is the sort of scenario they are really presented with, which can be quite absurd.

Mr Stokes —I think that is also exacerbated by the lack of representation often in hospital structures so that they cannot argue their case, and also by the industrial weakness that allied health professionals often find themselves in compared with nurses and doctors, for instance.

Senator LEES —Are you usually represented on, say, regional health boards? We have just heard from Barwon Health.

Mr Stokes —Very inconsistently. Generally not, but it varies across the country.

Mr Rhodes —Usually, I would say it is through a medical or nursing representative rather than through direct representation. With respect to other sorts of funding issues, private hospitals often do not provide post discharge allied health services. So the only way in which those services can be provided is by referral back to a hospital base. That is increased throughput in terms of the population that that department might serve. So it is not a driver by the institution they are employed by; it is a driver by the way in which the funding mechanisms create that additional work. There is not a growth factor in terms of the resources available to address it.

Some of the other issues that we would want to manage in terms of information relate to work force issues in terms of rural and remote capacity to recruit and retain people in those settings, which is often highly problematic for allied health, and especially so for very small professions like podiatry and so on. Additionally, teaching and training issues are fairly substantial for allied health. Most of our undergraduate student activity is largely sponsored by the hospital system. It is not specifically funded, so it does place at jeopardy some of those tertiary training programs. If staff are severely stretched or if there is a budget reduction, you have to cut down on student placements and the amount of time that it takes diverts away from clinical service provision. So you have always got that sort of tension of `should we be going in this or that direction?' Access by staff in terms of funding for professional development is also a very competitive field for allied health. We do not have the same mechanisms that medical and nursing staff may have to access that.

Finally, our research opportunities are somewhat constrained by not having suitable information systems upon which to develop research projects. We also do not have a good mechanism for when we do come up with good research outcomes to make sure that they are accessible to allied health staff so that we do not keep reinventing the wheel.

CHAIR —Mr Stokes, are you going to make a brief contribution?

Mr Stokes —Just a brief contribution, mainly towards the document that we have given you, as one example of the data development process and its impact on hospital funding for allied health particularly. In 1997, one of the first publications that the National Allied Health Casemix Committee produced was a document called The National Allied Health Casemix Committee's activity codes. In that we specified a minimum data set recommended for all allied health departments. We published a set of nationally agreed activity codes for allied health professions—at that stage 10 of them contributed to that process.

We also predicted the development of some other data set items, one of which was the indicator for intervention. The reason for that development was that, for many in allied health, at least anecdotally, they felt that DRGs did not well predict cost and activities of allied health. The rationale behind that, too, was that diagnosis was a poor springboard for patient outcome measures. For instance, in a setting where perhaps the diagnosis was stroke, diabetes or dementia—very common sorts of categories that allied health contribute to significantly in acute hospitals—there is no immediate suggestion of the reason for intervention or the benefit to the patient. You do not change those sorts of categories by your intervention.

More useful sorts of categories are things like mobility problems as a consequence of stroke; overweightness associated with diabetes or something of that nature, or interpersonal problems associated with dementia. Those sorts of categories are much more useful ways of describing the reason why the patient came for help, particularly allied health help, and gives you a basis for deciding on a performance indicator or some sort of outcome measure so that you can assess the benefits, change and impact of your intervention.

This leads us very quickly to the notion of evidence based practice, which of course is the Holy Grail of medical and health intervention programs. If you can demonstrate your effectiveness in the areas that you are talking about and that those measures are meaningful, then you have got some groundwork for developing information and evidence for the change that you have impacted on the patient. The indicator for intervention—or the IFI, as we have come to call it—was a very important development in giving us a foundation for both more clearly specifying patient groups and particularly leading us into outcome measures and performance indicator development. Just last year and part of the year before, with CDHAC funding, we were able to do stage 1 of this indicator for intervention development, which we felt was a very important data element. You have got a report of stage 1, but it is only stage 1, and we are very keen to see the development not only of the extension and refinement of these IFIs but also the development performance indicators based upon these IFIs. We think that is a very important process and project for us to continue in the validation of allied health as their contribution to the overall treatment context, particularly in acute hospitals.

CHAIR —Are your indicators in sync with the DRG part of casemix?

Mr Woodruff —DRGs are the health currency for hospitals. The indicators for intervention attempt to bridge back to the DRGs by way of the ICD-10 codes, which is a fairly complex way of saying that they do mesh but it is a complicated—

Senator CHRIS EVANS —I think you should translate that. I have got no idea what that means. It is part of the problem for the layperson in this debate. I have been calling for better statistical information throughout this inquiry, and then I got this and I am not so sure. I do not want to be rude but it is very complex. You have got to realise you are dealing with people who are not up with the terminology.

Mr Woodruff —To answer your question in lay terms would be to say that the DRG is a medical problem, disorder or disease that is being described and categorised. The indicator for intervention is something about the client that we attempt to address to improve their social, psychological or health state. Very often, they are not the same thing at all. We may be treating, as allied health professionals, something quite different from the admission diagnosis of the patient or client. To link those together—which is quite a challenge, because that is a medical system that we have to operate within—we have had to go back to the actual activities that are performed and the procedures that are conducted upon the patients and use those as a way of matching a DRG with our intervention or indicator.

CHAIR —So they do layer, one over the other?

Mr Woodruff —They intermesh rather than layer.

Mr Stokes —The difficulty is that, for a number of different DRGs, you might have the same sort of intervention. On the other hand, for one single DRG, you might have a multitude of different interventions. So, although they mesh, they do not exactly match. I can give you an example: dementia as a diagnosis can produce a whole range of indications for intervention and not the same for each dementia case.

Senator CHRIS EVANS —We fund for the DRG; we do not fund for the intervention.

Mr Stokes —Exactly.

CHAIR —I think if we keep talking, I will begin to understand. Can you turn to page 105 and take me through a line that says, `Performance Indicator (PI) = IFI + dimension factor'. This has got my hair beginning to stand on end.

Mr Woodruff —It is really very simple. We talk about performance indicators being outcome or performance measures. That is the PI. We would say that that is a composite of the reason that we saw the client—the indication for the allied health person doing something to the client. The indication might be a mobility problem, a memory problem or whatever.

CHAIR —So a performance indicator is an outcome measure. Why would I know that a performance indicator was an outcome measure?

Mr Woodruff —You might not, actually.

CHAIR —That is right. Stick with me because I am just trying to get this right. A performance indicator is an outcome measure?

Mr Woodruff —Yes.

CHAIR —Okay, and equals?

Mr Woodruff —Equals the indicator for intervention or the reason that we are actually doing something for the client, combined with one of the Commonwealth Department of Health and Aged Care's eight categories of performance dimensions. They have set up a national framework that says that if you are looking at outcomes for clients, they can be in the areas of access to service, safety of the service, continuity of the service, appropriateness and so on. So they defined a national template—which the states have actually ignored to a large extent—so that we can all talk the same language when we are saying that we are talking about an access performance or a technical proficiency performance, or whatever we are interested in. So we are linking our reason for seeing the client with the Commonwealth's categorisation of different types of outcomes to give a performance measure that is relevant to allied health professionals and is still very much focused on the patient or the client's needs and issues.

CHAIR —I have to say that I am still struggling to understand. I am not yet to the stage where I could say `PI equals six,' and we would all say, `Oh, very good,' or `Very bad'.

Mr Stokes —Can I give you a concrete example?

CHAIR —Please, get concrete.

Mr Stokes —Let us take an IFI in this formula—it is a substitute for the real thing.

CHAIR —Are we still on page 105?

Mr Stokes —We certainly are. An IFI might, in this case, be a mobility disorder—that is, the patient cannot walk easily. What we have added to that is the fact that we are concerned about the dimension, for instance, of safety. They have to return home: are they going to be able to manage with this particular indicator? So our performance indicator becomes a combination of their difficulty or disability, which in this case is their ability to walk, and the dimension factor, which happens to be safety. The perfomance indicator then might become something like `Can they return home?' That is what we are giving you an example of here. It is not just a question of the IFI, but also the other social or other contributing factors that are part of that, based upon those Commonwealth dimensions.

CHAIR —I do not wish to be entirely bloody-minded, Mr Stokes, but why could you not say: `Is this patient able to return home?'

Mr Stokes —But that is your performance indicator. What we are saying is what it is made up of and how we are going to predict the sort of performance indicator that is relevant to that patient.

CHAIR —So it is a fairly complex translation exercise to read this?

Mr Woodruff —It is if you are not in the health field—very much so. It is an attempt to convert a DRG into something that relates to a functional or social aspect of the client's status. Another example is someone who has had a stroke—that is the DRG—but really the main problem they have requiring allied health intervention is that they cannot speak any more. So the indicator is `speech problem' and the performance measure or performance indicator is, `How effectively have we treated the speech problem?' We need to measure that, rather than measuring something about stroke, which allied health does not directly treat.

CHAIR —On page 14, there is a long list, which I think is in your submission too, of categories of IFI. I am not sure—psychosocial factors, 110. Is 110 a code number?

Mr Woodruff —That is just a code number.

CHAIR —And that is cognition, meaning do they recognise blue as blue or grandma as grandma?

Mr Stokes —Anything to do with mental functioning, whether it be perception, memory, thinking, judgment or whatever.

CHAIR —Two hundred and ten: head and trunk control—which some of the Brumbies did not have the other night in South Africa. What is head and trunk control?

Mr Woodruff —This can relate to a range of DRGs. It could be related to a stroke in that the client can no longer hold their head up. That means they cannot return to their work as a proofreader or whatever, or it might be that they have a back injury and can no longer do certain things. It is teasing out the functional problem that the client sees, rather than describing the medical terminology of the DRG.

CHAIR —Two hundred and eighty: vestibular balance. I understand exactly what that is, but I want to know what other sort of balance there is.

Mr Woodruff —Vestibular balance relates to a balance problem relating to an ear problem, whereas there could be other forms of balance difficulty relating, for example, to a limb injury. It is very specific.

CHAIR —A very black comment there.

Mr Woodruff —Yes.

CHAIR —Okay. Senator Lees?

Senator LEES —I am fine at the moment. I have followed what has been said.

CHAIR —Senator Evans?

Senator CHRIS EVANS —I do not claim to have followed it as well as Senator Lees. I am getting to terms with it. I think you suffer from the fact that you should have been the first witnesses on this morning because this is pretty complicated stuff. I suppose it is not necessary that we get our heads around some of that.

Mr Stokes —No.

Senator CHRIS EVANS —It is interesting to see what you are doing. I want to go back to your submission which is stuff we need to come to terms with, and I guess it starts with the IT. We have been shocked at the inadequacy, from what has been told to us, of the IT networks inside hospitals and the inability to measure outputs. You have echoed it from your perspective, but it seems to be from all perspectives. Somebody said they are 25 years behind the banks in terms of IT development. That obviously has problems for you and also for the whole industry and for us in terms of measuring whether the health dollars are delivering. It seems we just do not know.

Mr Woodruff —Exactly.

Senator CHRIS EVANS —The next question then is: how can we solve that relatively quickly?

Mr Woodruff —The easiest answer to that question is to pour a lot of money into IT. It might not be the best answer. The step before that is to get a stocktake on what the level of access to IT is and what people would like to do with the IT systems. There are some very innovative programs occurring around the country with, for example, telemedicine, which relies very heavily on IT. In other places, as David as said, there is an allied health department or even a nursing division with no PC on the desk. I think we need a stocktake of: what do we want to use the IT information for and how will it improve efficiencies or change clinical practices?

Senator CHRIS EVANS —Are patients' records and inputs into the care of the patient still all done by handwritten notes and accessing their files?

Mr Rhodes —It varies, but most activities are paper based and often duplicated because of difficulty in everybody accessing that one paper based record.

Senator CHRIS EVANS —That takes me to the next point. The pressure is on from governments and hospital administrators to get people in and out quickly. You talked to us about discharge planning meetings. If everyone is doing day surgery, it seems to me that this is a bit of an old-fashioned concept, in the sense that they have gone before you have had time to have your meeting. I am not being flippant. It seems that we do not keep them in for days anymore because we want them out of the beds.

Mr Rhodes —Again, it depends on hospital activity, but most hospitals might be looking at about 50 per cent of activity as same day. The other 50 per cent is multiple day, from three or four days right through to rehabilitation.

Senator CHRIS EVANS —The evidence seems to be that we are putting a lot of pressure on to get them out quickly, so it raises the question: how do you run discharge plans?

Mr Woodruff —To run discharge planning you have pre-admission clinics. You have a good screening of the clients before they are admitted for the day or the day and a half or the half day, so that you can predict the sorts of complications that might occur and prevent them before they do occur, and you organise follow-up planning with the relevant professions that need to address the other issues. If the surgeon is operating on a fractured leg, that is fine, that can be repaired at the time, but there are flow-on effects with other professions that can be done.

Senator CHRIS EVANS —Yes, you know before the operation they are going to need physio and that they ought to be involved with a discharge plan. But how do we do that now? It seems to me we have this problem where we do not have the links with the hospital, that we are not running those inpatient services, pre-op, a lot.

Mr Woodruff —We are starting to have those pre-admission clinics more commonly, more for surgical because that is more predictable than medical problems.

Mr Stokes —That is a good point too. What you are saying is much more applicable to surgery, but there is a whole host of patients in there with medical disorders which are not as amenable and planable for as are the surgical ones. It is those patients that we get a lot more unpredictable costs from and where discharge planning and management is so essential at some point.

Senator CHRIS EVANS —What happens in terms of the allied health professionals role when they leave the hospital? Do you hand on your records to the local physiotherapist or podiatrist or does it stop when they go out and then start again?

Mr Woodruff —If you have the luxury of having someone being out there to hang on to in a publicly funded setting then, yes, you may be able to do that. But more often than not the patient has to come back as an outpatient to the hospital service to be followed up by the physiotherapist. You are right, they are in for a couple of days and if the physiotherapist does not have time to complete a regime of treatment, the patient has to come back.

Senator CHRIS EVANS —Do they all come back or do some just go off and purchase their own physiotherapy elsewhere?

Mr Stokes —That is an option. They can go to publicly funded community centres and so forth. Usually there is good communication, at least by phone, between the acute hospital setting and the community centre.

CHAIR —It is a good example, is it not, of one of the shining examples of how bad it is in that the need for physiotherapy is not matched in the public sector, particularly outside of the public hospital? It, more perhaps than some of the other areas of allied health services, is a real problem for patients. A lot of them actually forgo physio.

Mr Woodruff —It is actually fairly common across the whole range of allied health professions.

CHAIR —Do you mean the shortage?

Mr Woodruff —Yes. The real crux of it is that if you fund public hospitals by DRGs for their in-patient care and the allied health professionals are seeing the patient back as an outpatient, we have a different fund base. If you capture that component of allied health care that they use as an in-patient, it is probably quite small, and you have no way of putting back in the extra time, energy and resources that were spent on return as an outpatient. That compartmentalisation of funding is the real issue.

Senator CHRIS EVANS —What value is there in the hospital taking them back in as an in-patient? How is that funded?

Mr Woodruff —It is very much a disadvantage if they are readmitted. There are lots of penalties for unplanned readmission to hospital.

Senator CHRIS EVANS —What about them accessing services as an outpatient of the hospital?

Mr Stokes —They come out of a different funding stream then because it is now an ambulatory care clinic and that is a different bucket, a different column or a different silo—whichever.

Mr Rhodes —The direction that clinicians want to go is not for people to come back to hospital at all but to access a service that is much more in their own community setting.

CHAIR —In whose own community?

Mr Rhodes —The patient's. Rather than having to travel back in for treatment on a routine basis, the clinicians want patients to provide something more innovative and coordinated in their own communities.

CHAIR —I thought the question that Senator Evans asked was based on the fact that there are sometimes perverse incentives for people to be readmitted because that provides more money for the hospital. You would probably have to call it some kind of illness. There may be penalties, but we have also been advised in a number of cases that there are distinct advantages in popping them out early and getting them back in again because it is a new admission and more money.

Mr Woodruff —That does occur. I think it occurred much more in the past than it does now. That manipulation of classification of readmission has been tightened up fairly dramatically, in my experience. It is not an area that allied health has a lot of discretion and control over in those sorts of readmissions for whatever purposes.

CHAIR —It was the casemix DRG funding that I was hoping you might be able to help us with, and you have, thank you.

Senator CHRIS EVANS —You talked before about being out of the loop in terms of what drives the hospital and the patient treatment. It raised in my own mind how we determine how many allied health professional services we use and where we put them. Is that just left to individual hospital decision making?

Mr Rhodes —It is, and it is very much not substantiated by anything of rigour, and that is what we are basically arguing. With our capacity to generate good information about what is needed, it is always going to be very much a local political decision and outcome as to what resources are allocated to allied health and between allied health professions.

Senator CHRIS EVANS —If the administration of a hospital has a view about one of the allied health professionals not being particularly useful or not terribly good at generating income, then they might not give it much priority. It is not based on medical need or any established criteria. Is that what you are saying?

Mr Woodruff —That is right.

Mr Rhodes —It is often based on the obvious symptoms rather than the more disruptive and less obvious symptoms. You talked about the awareness of physiotherapy, and that is because it is so much easier to see a physical disability. But sometimes intellectual or social disabilities are much more disruptive and costly and yet they are less obvious. It is on those sorts of bases that decisions are often made.

Senator CHRIS EVANS —I suppose people will say, `What's that got to do with the hospital?'

Mr Woodruff —Yes. There is often a view that, if we can get them out of the hospital and acquit ourselves of our role in the medical and nursing treatment, then the client's other issues are something that can be dealt with by the community, the GP or some private facility.

Mr Stokes —Except that if your patient cannot be discharged because you cannot send them home in that condition, then you have a problem. Those sorts of issues come up.

Senator CHRIS EVANS —A lot of their problems would not be that bad, but getting them out of the hospital door is really what—

Mr Woodruff —They are not based on a medical perspective. Their major concern might be their inability to swallow solid food after their stoke, but from a neurological point of view, the neurosurgeon says, `They're fine and they can go home.' It depends on whose perspective you want to use.

CHAIR —I am interested in whether we know a little more perhaps in pre-planning what might happen if a person does have a broken leg. I guess if you have a broken leg, there is not usually time to sit around and think about, `Let us have a pre-treatment conference.' They are usually raced in with sirens wailing. But we take your point. That is perhaps not the best case to illustrate it, but surgery means they are coming in from elective surgical procedure, you can anticipate or whatever.

We have also heard a lot of evidence that terrible things occasionally happen to people in hospitals, so what looked like being a straightforward surgical procedure now turns out to be a major disaster. This person has gone off their face after the effects of the anaesthetic. They have fallen out of bed and broken an arm. They are now retaining urine. They suddenly need all the allied health that you can give them. That is post-operative procedure and that certainly happens sometimes. We have also been advised about the medical patients, particularly as many of the patients admitted to hospitals are getting older and older. What might look like a straightforward medical assessment—a heart condition or whatever—turns out to be another potentially long-stay problem . Can you comment, in both of those categories, on how you see yourself with that interface there?

Mr Woodruff —My problem is really couched within the concept of the indicator for intervention. If a client comes in with what seems to be a relatively simple medical or surgical problem but they then fall out of bed and break their leg because they have poor mobility, it really is an issue of their not being adequately screened on admission for their risk of other complications. If the indicator for intervention screen was there and it said, `Check this person for mobility' and you therefore put the bed sides up or took some preventative action, you would prevent that complication occurring. You can make those same arguments about some of the complicated medical and surgical issues such as renal failure: if their dietary control was managed immediately on admission, they would not develop a high blood potassium level so they would not require additional dialysis. It is a matter of assessing the needs of the client from all perspectives, not just the medical or surgical treatment. That is not being done yet, mainly because we have just started to set up this system of screening by indicators for intervention.

CHAIR —What is going to happen to your report?

Mr Woodruff —It is going to be sent to all state and territory health departments. There is a set of recommendations in there that those departments start using our national templates for data collection and reporting. It will go back to the Commonwealth department of health and we will argue vigorously that they fund further phases so that we can really get up to speed with what medicine is able to do with its fund base to start demonstrating the value of Allied Health in interventions and the way that they contribute to efficiencies in the system.

Mr Rhodes —It is very much a precursor and that is why it is probably pretty idiosyncratic to ask these things, although we can understand it. What we are really aiming for is developing some outcome measures that make sense in terms of what we do. But to do that, we have to understand, `Why did we actually get involved with this person in the first instance?' This is just defining that patch. What we want to get to is: if Allied Health were involved, what is the positive health gain to the patient in relation to that intervention?

CHAIR —I think that is a very useful contribution to our deliberations. I am not sure that I will be able to phrase it in `PI + IFI', but what you are talking about, as has been explained and elaborated on, is very much one of the concerns that the committee has. I thank you very much for your information. If there is more that you need to tell us, please feel free to do so. If we have further questions, may we contact you for further answers?

Mr Woodruff —Certainly.

CHAIR —Thank you very much.

Proceedings suspended from 3.19 p.m. to 3.35 p.m.