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COMMUNITY AFFAIRS LEGISLATION COMMITTEE
HEALTH AND AGEING PORTFOLIO
Food Standards Australia New Zealand
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COMMUNITY AFFAIRS LEGISLATION COMMITTEE
Department of Health and Ageing
Food Standards Australia New Zealand
ACTING CHAIR (Senator Siewert)
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COMMUNITY AFFAIRS LEGISLATION COMMITTEE
(Senate-Wednesday, 3 June 2009)
HEALTH AND AGEING PORTFOLIO
Department of Health and Ageing
Senator CAROL BROWN
Australian Sports Anti-Doping Authority
Australian Sports Commission
Private Health Insurance Administration Council
Senator CAROL BROWN
Food Standards Australia New Zealand
ACTING CHAIR (Senator Siewert)
Australian Organ and Tissue Donation and Transplantation Authority
- Department of Health and Ageing
- HEALTH AND AGEING PORTFOLIO
Content WindowCOMMUNITY AFFAIRS LEGISLATION COMMITTEE - 03/06/2009 - HEALTH AND AGEING PORTFOLIO - Food Standards Australia New Zealand
CHAIR —Welcome. Senator Boyce, you can start.
Senator BOYCE —I have a group of specific questions around Bisphenol A—BPA—which is an artificial oestrogen found in plastic baby bottles, I understand, and I am told, that over time, the heating of the bottles can lead to this artificial oestrogen leaching out of the plastic and into liquid in the bottles. Can you tell me what work FSANZ has done in this area, please.
Dr Brent —You are talking about Bisphenol A, or BPA, and it is a chemical found in polycarbonate plastic items such as plastic baby bottles and so on.
Senator BOYCE —Is it all polycarbonate products?
Dr Brent —It is very commonly used. It is a chemical that makes the plastic flow better, so it gives it better properties to be moulded and so on. In terms of its safety, there have been quite a few recent reviews of the scientific literature. Most notably, the European Food Safety Authority has done a review of its safety, and also the USFDA has done a review.
Senator BOYCE —Could you give me the dates for those, Dr Brent. When you say ‘recent’, what dates?
Dr Brent —2008 for both of those. Our agency has also looked at all of the available data and the consensus seems to be that, at the levels people are being exposed to from consumption of beverages or food products from plastic bottles, there is no safety issue. I guess some of the risk management decisions that have been taken in other countries have got into the media. Certainly Canada, for example, came up with exactly the same conclusion: that there is no human health and safety issue even in young children from the consumption of beverages from these bottles at the dietary levels we are exposed to.
Senator BOYCE —When you say there was a consensus about the very low levels of danger, the consensus is from those literature reviews. Is that what you are saying?
Dr Brent —That is exactly correct.
Senator BOYCE —I understand that the use of BPA in bottles used for babies, at the very least, or containers used for baby products made with polycarbonate in the US, has been made illegal. Is that correct?
Dr Brent —No, that is not correct. I think you may be referring to Canada where, as I said, the Canadian food regulators came up with the same view on the safety—that is, that there is very little safety concern at the levels people are being exposed to, even for young children. But the Canadian government decided to take a risk management decision and they are looking to phase out the use of BPA, particularly in babies’ bottles, and are working closely with industry to look for alternative substances to do what this particular substance does in the plastic. I believe also that the Canadians have been discussing and negotiating similar activities perhaps in the US, because they share a border, obviously.
Senator BOYCE —Yes.
Mr McCutcheon —There have been reports coming out of the US which have really not represented the true situation. For example, Suffolk County in New York announced on 2 April this year a ban on the sale of BPA-containing bottles and cups intended for young children, so there has been some action at that level, and then similarly, on 8 May 2009, Minnesota enacted a bill banning certain products containing BPA. So there has been some sort of action at the state and local, or county, level in the US but nothing at the national level, the federal level.
Senator BOYCE —Nevertheless, we are talking about babies, and people obviously would rather err on the extremely cautious side than be taking any risks at all. In the research that you referred to we are obviously talking about different risk levels for an adult compared to a child. Would you like to describe what those risk levels are, please.
Dr Brent —The research that has been done looks at the toxicological end points, particularly in animals, for this substance, and they do reproductive studies and multigenerational studies.
Senator BOYCE —So we are stuffing vast amounts of this into mice or rats to see what happens.
Dr Brent —That is correct. The final health reference end point that they get to actually takes into account the toxicity in a range of ages, adults down to children. In terms of the multigenerational reproduction studies that they do, that is how they look at the effect on young kids.
Senator BOYCE —Would you be able to quantify this in any way? What I would love is for you to tell me, ‘Well, the parts per million that a baby might get are X, and the dangerous parts per million would be something else,’ but I will accept anything along those lines that you might be able to tell me.
Dr Brent —In terms of a level that is safe, did you say?
Senator BOYCE —Yes, or unsafe.
Dr Brent —I am unable to give you a figure right now. I would have to take that on notice, if there is such a figure.
Senator BOYCE —Yes.
Dr Brent —I am happy to take it on notice.
Senator BOYCE —I am presuming there would be a figure at which oestrogen that is not naturally occurring—oh dear, yes, we could get into a really long argument here, couldn’t we! I was just thinking of other ways that this could happen. Have you done any independent research in this area?
Dr Brent —We do not do research, but we have done our own independent assessment of the available literature, and we have come to the same conclusion as the European Food Safety Authority and the USFDA and, indeed, the government of Canada—the Health Canada Food Directorate. We are in contact with these people on a regular basis. In fact, we had a teleconference last Thursday night with all of those regulators.
Senator BOYCE —On this issue?
Dr Brent —No, not on this issue, but we have spoken about this issue in the past, particularly with Canada. We are all on the same page: that even in young children there is unlikely to be any human health and safety issue at the levels people are being exposed to.
Senator BOYCE —Are you aware if the bottles and cups used for Australian babies are generally of Australasian manufacture, or are they imported?
Dr Brent —Again, I will have to take that on notice.
Senator BOYCE —Have you had conversations with any local manufacturers on the topic of babies’ bottles or cups?
Dr Brent —I guess we have had some contact with the AFGC on some of these issues, but I am not aware of who is making baby bottles here in Australia.
Senator BOYCE —Thank you.
ACTING CHAIR (Senator Siewert) —I would like an update on where we are up to with the food labelling issue. A number of us ask this question every time we have estimates. I believe there may have been a little bit of progress. Is that correct?
Mr McCutcheon —We might just get you to clarify, when you talk about the ‘food labelling issue’, what—
Senator McLucas —Which one?
ACTING CHAIR —You were undertaking some work—and this goes back to when we were asking those questions in the chamber about whether we were going to go to stoplight approach or—
Senator McLucas —Traffic lights.
ACTING CHAIR —Traffic lights, sorry. There was talk about it at ministerial council and you were progressing it from there. So what I would like to know is where we are up to now.
Ms Halton —It has not actually been referred to FSANZ yet. It is still a matter in front of—well, not quite yet in front of the ministerial council.
Senator McLucas —That is right.
ACTING CHAIR —Parliamentary Secretary, where is it up to in ministerial council? We had this debate a significant period of time ago in the chamber, where it was being referred—
Senator McLucas —There is an item that has been in front of the last MINCO—and, in fact, the one before—a reference to undertake a comprehensive review of labelling law and policy by the ministerial council on food regulation. At the last ministerial council there was agreement around some draft terms of reference. The area that we do have to agree on is the funding source for this work.
ACTING CHAIR —How much is it going to cost? What sort of funding are we talking about?
Ms Halton —For the review?
Senator McLucas —My recollection was $1 million.
Ms Halton —It is $1 million. That is the upper estimate, but that is certainly the estimate of the costs of that review.
ACTING CHAIR —Could you remind me when the last work was done on food labelling?
Senator McLucas —I have only been in this job for a little over 18 months, and my understanding is forever.
ACTING CHAIR —That is what I thought.
Ms Halton —It certainly precedes my time.
Senator McLucas —It just goes on and on, and that is because of the changing demands of consumers and the changing desires of manufacturers. I think it is an ongoing story, but we certainly support the idea of doing some sort of ‘line in the sand’ comprehensive review.
Ms Halton —Proper review.
Senator McLucas —At the moment, I think it is timely, because we really do have a lot of demands from industry, consumers and public health activists wanting to be part of a discussion around labelling.
ACTING CHAIR —It has been on the last two agendas. Is that what you said?
Senator McLucas —That is right.
ACTING CHAIR —When is the next meeting?
Senator McLucas —October.
ACTING CHAIR —If it does get referred, then we are talking a significant period of time. There are, as I understand it, statutory requirements for FSANZ to—
Senator McLucas —This would not necessarily be referred to FSANZ.
ACTING CHAIR —We would not do it under that process?
Ms Halton —No.
Senator McLucas —This would be done by FRSC and probably subgroups of officers.
Ms Halton —As the chair of FRSC, we would actually run that process on behalf of the ministerial council. The principal challenge at the moment is sourcing the funds to do it.
Senator McLucas —That is right.
Ms Halton —There is a great deal of goodwill about doing that review, I would have to say. There is almost universal agreement that we should do it. The challenge is finding the cash.
ACTING CHAIR —Are you expecting the states to stump that up as part of a joint approach through the ministerial council?
Ms Halton —Essentially, as you probably know, there is money that was provided to the states as part of the whole COAG regulatory reform agenda, and the Commonwealth starting position on this, as advised by our Treasury and central agency colleagues, is that that is exactly the kind of thing that the funding was provided for and so it would be helpful if the states could actually tap into those funds. We are waiting for a response, aren’t we?
ACTING CHAIR —Thank you. In terms of the labelling on wine bottles and other alcoholic products, where are we up to with that review?
Mr McCutcheon —There is no specific review on labelling of wine products and other alcoholic beverages. If you are referring to an application for—
Ms Halton —There is in terms of standard drinks, on alcohol, yes.
Mr McCutcheon —That is the COAG. Is this following on the discussion—
ACTING CHAIR —I thought there was an agreement through COAG.
Ms Halton —Yes.
Mr McCutcheon —Sorry, yes. I am getting confused with the other applications that were discussed at the last hearing.
Ms Halton —Switch track. Go to the next issue.
Mr McCutcheon —That is a process under COAG. FSANZ was asked to prepare a report, which we have done. That was submitted to the ministerial council and it, in turn, will forward that on to COAG.
Ms Halton —Essentially, it will go to the Ministerial Council on Drug Strategy because, as you are aware, the whole binge-drinking approach comprises a number of different elements, of which that labelling work is only one component. So that ministerial council is looking at the entire package, with a view then to taking it to COAG.
ACTING CHAIR —So it is not going to go up separately?
Ms Halton —No. Correct.
ACTING CHAIR —What is the time line for that, for the whole binge-drinking package going up then?
Senator McLucas —The element that FSANZ completed for us is complete. It was accepted by the ministerial council on food regulation a couple of weeks ago. We have now forwarded it to the Ministerial Council on Drug Strategy, and the view is that that then will be pulled together and sent directly to COAG.
ACTING CHAIR —So it will be at the next COAG meeting? Would that be your intention?
Senator McLucas —We do not control the COAG agenda.
ACTING CHAIR —Sorry, I will rephrase that. You will have it ready for the next COAG meeting.
Senator McLucas —That is correct.
ACTING CHAIR —Thank you. Senator Colbeck, welcome.
Senator COLBECK —I just came in to listen to FSANZ stuff on food labelling, given that we asked some questions about it in agriculture last week and were kindly referred here. Senator Siewert has dealt with that. A curiosity question: AQIS last week removed irradiation for cat food as a quarantine measure for product being imported into Australia on the basis of neurological problems in cats.
Ms Halton —I think it was actually cat deaths, wasn’t it? ‘Neurological problems’ is a nice way—
Senator COLBECK —Created neurological problems. How is Princess by the way?
Ms Halton —Princess is excellent, thank you. For those in attendance who do not know, Princess is one of my cats. She looks distinctly like Garfield, but she is a girl: orange and quite large.
Senator COLBECK —We have been acquainted with her, I think, at a previous estimates hearing.
Ms Halton —She is doing very well. Thank you for your concern. I will pass on your regards.
Senator COLBECK —We have cats in our household, so I understand perfectly—including some of the neurological issues too, I think—or it might be psychological. The question is: does it raise any further issues? My understanding is that there were not issues with respect to dogs, although there are still some concerns with respect to the labelling of dog food—and I understand that is not necessarily your problem. But I just wondered if it raised any other issues?
Mr McCutcheon —We certainly have been in regular contact with AQIS and Biosecurity Australia on that issue, because it certainly did raise some questions, but the bottom line is that it is not an issue for human food, and I understand it is a particular issue for cats. But I might ask our chief scientist. He can talk probably through the detail a little better than I can.
Senator COLBECK —That would be good, thanks.
Dr Brent —Thanks. In fact, I think you have said it all. It does seem to be an issue for cats specifically. We do not know how the irradiation affects this particular cat food, and it only seems to be a specific type of cat food, which I am told is very expensive. It is an imported type of cat food. We have had meetings with AQIS and Biosecurity Australia and the Australian Veterinary Association, and also the cat neurologist, Georgina—I cannot remember her second name, sorry—from the University of Sydney veterinary school. As I say, the cats seem to get ataxia and then they get paralysis of the hind legs and that does go on to death. I think about 90 cats so far have been affected, of which about 30 died, so it is a bit of a conundrum. In terms of human food, we do have a standard for food irradiation, but there is absolutely no association of any kind with any human health and safety issue with the consumption of irradiated food.
ACTING CHAIR —This was an issue that we were discussing last week in the rural and regional committee, and I did ask the question, ‘What does it mean for irradiation of foods that humans eat?’ Can you tell us how you know it is not an issue for human food?
Dr Brent —We only allow irradiation of herbs and spices and tropical fruits. They are the only foods that are allowed to be irradiated so far. When we receive an application to approve an irradiated food, we get a whole suite of data, and there is no inkling at all, or any evidence at all, that there is any issue in terms of human health and safety.
ACTING CHAIR —Presumably there was not for the cat food either originally.
Dr Brent —No, that is correct.
ACTING CHAIR —The point is that the cat food has obviously proved to be a problem.
Dr Brent —I am not sure that cat food is actually tested before it is produced or consumed by cats or dogs. I do not know that anybody is testing pet food.
Mr McCutcheon —To add to the answer: firstly, the levels of irradiation that are used, as I understand it, for foods for human consumption are of a very narrow range. They are at significantly lower levels than they are using for cat food. Secondly, the detailed questions about cat food are really outside of our remit.
ACTING CHAIR —I appreciate that.
Mr McCutcheon —We are commenting on stuff we have picked up from meetings with AQIS and BA.
ACTING CHAIR —The point there, though, is that we were told last week that what is used to irradiate imported cat food is very low. Are you saying that the irradiation that is used for food for human consumption is lower than that which is used for pet food?
Mr McCutcheon —Very much lower, yes.
ACTING CHAIR —Can you provide us with a list of what is now allowed to be irradiated.
Mr McCutcheon —I can give you that list right now. Standard 1.5.3 of the Australia New Zealand Food Standards Code permits the irradiation of herbs, spices and herbal infusions to destroy food-poisoning bacteria and control insect infestation, and also to delay sprouting and destroy weed seeds. The specified tropical fruits that are permitted to be irradiated are breadfruit, carambola, custard apple, lychee, longan, mango, mangosteen, papaya and rambutan.
ACTING CHAIR —They are the only foods that are currently irradiated in Australia?
Mr McCutcheon —Permitted to be irradiated, and for quarantine purposes.
ACTING CHAIR —And for quarantine purposes?
Mr McCutcheon —For those fruits, that is correct.
ACTING CHAIR —If they are imported?
Mr McCutcheon —That is right. The irradiation permissions for the tropical fruits were set up mainly for quarantine purposes, to do with imports. With the other foods that I mentioned—the herbs, spices and so on—the irradiation is designed to destroy food-poisoning bacteria and so on, so it has slightly more a food safety component to it.
ACTING CHAIR —Thank you for that.
CHAIR —There being no further questions of FSANZ, I thank the officers.
CHAIR —We will now move to outcome 13, Acute care and program 13.3, Public hospitals and information.
Senator BOYCE —My first questions are just trying to get some information—and I have asked similar questions of FaHCSIA—on the fact that quite a lot of your appropriations will be coming through Treasury rather than through Health and Ageing. Could you talk me through how that works and what happens. What controls do you have, in that you are still the policy and program driver? How do you know how that is all working?
Ms Yapp —Treasury will be responsible for the funding and the policy arrangements around the SPPs but the department will have responsibility for the national healthcare agreement.
Senator BOYCE —But you would have paid out those SPPs in the past.
Ms Yapp —That is right.
Senator BOYCE —So how does Treasury know to pay them out, so to speak? That is what I was wanting to go through.
Ms Yapp —The arrangements for the SPPs are set out within the intergovernment agreements. With the overarching SPP for health care, Treasury will pay a standard amount each month, on the seventh of the month.
Senator BOYCE —They pay it out monthly.
Ms Yapp —That is right.
Senator BOYCE —But there is a performance measure in there, is there not?
Ms Yapp —In regard to the healthcare SPP, the only requirement is that the money be spent on healthcare services. In terms of the overarching healthcare SPP, that is the only requirement attached.
Senator BOYCE —Is that monitored?
Prof. Calder —There is an agreed set of performance indicators across the healthcare agreement that will be monitored over time.
Senator BOYCE —So that monitoring would continue to be done by the department?
Ms Yapp —The monitoring will be done both by the department and by the COAG Reform Council, who will be collecting and reporting the whole range of indicators against all of the different agreements and national partnerships.
Senator BOYCE —Excuse my terminology here, but it is almost like a monthly direct debt from Treasury to the states for the SPPs. Is that right?
Ms Yapp —For the overarching SPP, the healthcare agreement SPP, not the national partnerships.
Senator BOYCE —But you would still have overall responsibility for ensuring that the performance indicators for the overarching specific purpose payments are being met.
Ms Yapp —The performance indicators are linked to the national healthcare agreement, which is related to but not the same as—
Senator BOYCE —The partnership agreement; is that right?
Ms Yapp —The SPP.
Senator BOYCE —If you are thinking of a way to make this clearer, I would love that. Thank you.
Senator WILLIAMS —Are you saying that they just give the money to the states and each state decides how it is distributed?
Ms Yapp —That is right.
Senator BOYCE —In that area?
Senator WILLIAMS —Yes, in this area.
Ms Yapp —That is right.
Senator COLBECK —Is that a part of the process where payments to states from a number of agencies will be lumped into one payment made to the states on a monthly basis but the management and the oversight of the relevant programs for which those payments are made remain with the agencies? For example, in agriculture, drought payments are being made through Treasury now instead of by the department of agriculture.
Senator BOYCE —FaHCSIA is doing the same thing.
Senator COLBECK —It sounds like there is a lumping up of payments to the states.
Ms Halton —I think it is called ‘streamlining’.
Senator COLBECK —‘Lumping up’, ‘streamlining’.
Ms Halton —So essentially the Treasury had that responsibility for those macro transfers. We are still responsible for issues around—we have already discussed this cost shifting, for example—those matters which are in schedules to that agreement. As Ms Yapp is indicating, the COAG Reform Council is responsible when it comes to performance monitoring at the macro level, particularly in respect of reward payments, whether or not the states and territories have achieved those particular objectives to which reward payments attach and, indeed, whether those reward payments will be made.
Senator COLBECK —So those triggers come from you to Treasury to make those payments or otherwise?
Ms Halton —Yes, that is right.
Senator BOYCE —Is it a direct debit system or is it a trigger system, and does it vary depending on the payment?
Ms Halton —It varies. That is exactly right.
Senator BOYCE —Which payments are automatic and which are performance based? That is an answer I would like.
Ms Halton —We might give you an answer on notice to this, because we can set it out in writing—
Senator BOYCE —In a lovely table. That would be beautiful.
Ms Halton —In a lovely table, so that you can see how all those bits fit together.
Senator BOYCE —That would be very good, thank you, because this would seem to be a logical continuation of the splits that went on, for example, between the development of the Department of Human Services and leaving policy in other departments. But the issue that we are concerned about is: is the accountability still going to be resident with the policy-driving department? On the topic of public hospitals themselves, would it be possible to get a baseline table of all the current public hospitals in Australia and their locations and how that will change over the forward estimates period?
Prof. Calder —Are you asking about the physical location of hospitals?
Senator BOYCE —Yes.
Prof. Calder —The numbers and the locations?
Senator BOYCE —Numbers and locations.
Prof. Calder —We can certainly provide you with that data.
Senator BOYCE —On notice?
Mr Eccles —We might be able to give you a list of where the hospitals are across Australia, but I do not think we can give you the amount of money that the states provide to each of their hospitals.
Prof. Calder —No, we cannot.
Senator BOYCE —No, I did not ask for that. Number of hospitals by state and location—
Mr Eccles —Yes.
Senator BOYCE —and how much each will be getting under the forward estimates.
Ms Halton —Each state?
Senator BOYCE —Each hospital.
Mr Eccles —We will not be able to provide that. To be clear, we can give you an understanding of where all the public hospitals in Australia are and we will be able to give you the amount of money that each state gets.
Senator BOYCE —We have got this big investment in infrastructure. How many more hospitals are we expecting per state and, if not a new hospital per state over the forward estimates, what development of a hospital?
Ms Halton —Are we now talking about the Health and Hospitals Fund?
Senator BOYCE —Yes.
Ms Halton —The infrastructure investment?
Senator BOYCE —Yes.
Ms Halton —We have chapter and verse on the investments. So we can say in those cases where the money is going.
Senator BOYCE —That would be good.
Mr Eccles —Not a problem.
Ms Halton —So you are talking about the capital investment in infrastructure that is coming from the Health and Hospitals Fund?
Senator BOYCE —That is being spent for infrastructure on public hospitals in the states over the forward estimates.
Ms Halton —Right, but that is different to the moneys that are coming through Treasury under the agreement that was struck at COAG.
Senator BOYCE —Yes.
Ms Halton —Good. We are on the same page.
Senator BOYCE —I want to know how many hospitals we have got now, where they are and how much money is going towards more hospitals or bigger hospitals over the forward estimates.
Ms Halton —Not a problem. Got it, no worries. We are all clear, so you will not get something which is not what you are expecting.
Senator BOYCE —The other questions I had in this area were more around the changes that are going to be made to hospital accountability and performance programs. The priorities under the national healthcare agreement is where I am at. We are talking about a nationally consistent approach to activity based funding for services provided at public hospitals as the major and first priority, and yet this afternoon we had a situation where I was asking about the definition of ‘capacity alert’, which apparently is a Queensland health definition, and the response I got was that this was not a national definition. Could you please tell me how we are going to end up with a nationally consistent approach to activity based funding for services provided at public hospitals if we do not even have nationally consistent definitions of what is a bed, what is a waiting list, what is capacity et cetera?
Prof. Calder —That is the work that is under way to achieve that national body of data.
Ms Clarke —We are working on activity based funding, and there are nationally agreed definitions for waiting times, beds and the like in the National Health Data Dictionary that is managed by the Australian Institute of Health and Welfare.
Senator BOYCE —Is that used by all states?
Ms Clarke —Yes, it is in relation to the national collection of data and the Commonwealth uses it—
Senator BOYCE —When you say ‘in relation to the national collection of data’, there might be times when they would not use it?
Ms Clarke —I think that the Australian Institute of Health and Welfare would be better placed to answer that question directly, but my understanding is that the standards are used and the dictionary definitions are used where they can be in the national data collection, and at the state level as well.
Senator BOYCE —Where can’t they be?
Prof. Calder —Perhaps I could come at that question from another direction and point out that the work that is under way is to achieve nationally consistent classifications for a range of hospital services, including emergency departments, for example, which goes to the question you asked earlier today. So there is not a complete set of agreed classifications. That is the work that is under way.
Senator BOYCE —I want to get some sense of how far you think you are down the track of developing a nationally consistent set of measures that will assist in assessing all public hospital activities that need to be assessed.
Mr Eccles —The department is working with the states and territories, the AIHW and the ABS to ensure that there is national consistency around a whole new suite of performance indicators, which will then form part of the performance framework against which the COAG Reform Council is going to monitor the performance.
Senator BOYCE —I was going to ask about the performance indicators, but keep going.
Mr Eccles —Earlier today the National Health Information Standards and Statistics Committee, which is a subcommittee of AHMAC—
Ms Halton —Which is, of course, completely riveting to attend, Senator.
Senator BOYCE —I would like to see the minutes!
Mr Eccles —They met today and there are in the order of 40 indicators.
Senator BOYCE —There are 40 performance indicators?
Mr Eccles —That is right, or in the order of. I have not added them up. We can make sure you have got that information; it is publicly available. The states and territories, the Commonwealth, the ABS and AIHW are working systematically through those indicators to ensure that there is a nationally consistent approach so that we are measuring apples against apples, to make sure that the data definitions are right, and with a view for that information, once the data is able to be collected, to go through to the COAG Reform Council.
Senator BOYCE —So under each of those 40 indicators there might sit one or many definitions that need to be made consistent.
Mr Eccles —Exactly right. The first task of that group was essentially to divide the indicators up, with different jurisdictions, different individuals, taking the lead in bringing together working groups so that they can work through the definitional differences to make sure that there is the ability for alignment.
Senator BOYCE —How many working groups are working on this at the moment, Mr Eccles?
Mr Eccles —I do not know. Our relevant expert is actually in South Australia attending this meeting. They will be here tomorrow, so I will be able to give you that information or take it on notice.
Senator BOYCE —Can you tell me how many working groups, and do we have a sense of where this work is at? Are they five per cent down the track? Are they 60 per cent down the track?
Mr Eccles —There is a requirement to have data available at the end of the year to the COAG Reform Council.
Senator BOYCE —The end of the calendar year?
Mr Eccles —The end of the calendar year, so that they can report in March 2010. They are at various stages and they are prioritising those that are the hardest. In fact, it would be quite useful: I will be able to get you an update tomorrow about how the work program is progressing.
CHAIR —Which outcome are they going to be in tomorrow, Mr Eccles?
Mr Eccles —It could be covered under outcome 10.
CHAIR —‘Health system capacity and quality’.
Mr Eccles —Yes. That is where a lot of our data expertise is.
CHAIR —Senator Boyce, we will actually make a note for your questions to go into outcome 10.
Senator BOYCE —Okay.
CHAIR —Thank you, Mr Eccles.
Senator BOYCE —If we have started that work and expect to have it finished by December, but we are already paying out under the National Healthcare Agreement for this work for the hospitals to be activity based, have we got the cart before the horse? How do we assess performance of their activities right now?
Mr Eccles —I do not think we could stop the payments while we get our collective data act together.
Senator BOYCE —So you will be stopping payments—
Mr Eccles —No, we have to get the data together, and that process is under way, and in the meantime payments are continuing.
Senator BOYCE —So how do you know how they are going?
Mr Eccles —There is still reporting—and Ms Clarke will be able to take you through it—in The state of our public hospitals report.
Senator BOYCE —Yes, all right.
Ms Halton —Can I add to that, Senator. We did cover this very briefly this morning. In relation to some other areas—and we talked a little bit this morning about elective surgery—we have got specific reporting coming in against those sorts of things.
Senator BOYCE —I wanted to talk a bit more about elective surgery.
Ms Halton —Yes, that is fine. Essentially, what we have here is this new financial framework, which is quite an extensive change, compared to where we were previously. We have had some efforts in respect of data in the past, and national consistency. This really sharpens the focus on the need to not collect 25,000 million data items but to collect against the ones—
Senator BOYCE —No, but if we could have a nationally agreed view of what ‘hospital bed’ is—
Ms Halton —Yes, exactly.
Senator BOYCE —or what ‘capacity’ is. I know these are not easy things to arrive at.
Ms Halton —No. I think capacity is a more difficult issue because that is an operational matter, which is about how these things are run, but the capacity to compare both costs and activity across these systems, I think, is really at the core of what it is we are trying to get to.
Senator BOYCE —Yes. Sorry, someone was going to tell me about reporting.
Ms Clarke —Sure. The performance of public hospitals currently under the Australian healthcare agreements is reported annually in The state of our public hospitals report. The last one was released in June last year.
Senator BOYCE —And you are working on the next one?
Ms Clarke —Yes, we are.
Senator BOYCE —When are you anticipating that would be released?
Ms Clarke —The report must be released by 30 June of each year.
Senator BOYCE —On 30 June or before 30 June? Is it currently with the minister?
Ms Clarke —We are working on it currently.
Senator BOYCE —The department is still finalising it. Is that right?
Ms Clarke —Yes.
Senator BOYCE —Do you have all the data from all the states?
Ms Clarke —The states must submit data for the reporting purpose and for compliance reasons by 31 December of each calendar year.
Senator BOYCE —So you are reporting in June on how they performed in calendar year 2008. Is that correct?
Ms Clarke —No, they are reporting on the financial year, so the report released in June of last year was 2006-07 data.
Senator BOYCE —So The state of our public hospitals is really 12 months old, isn’t it, by the time it becomes a public document?
Ms Clarke —The data.
Senator BOYCE —Yes, sorry. I did not mean to imply that the report was old, but the data is 12 months old.
Ms Clarke —Yes.
Senator BOYCE —So it does not really assist us or the Australian public to know if state hospitals have improved in their performance over the past 12 months, given (a) the amount of money that has been thrown at them and (b) the statement that the Prime Minister made about simply taking them over if they did not do the job.
I am just looking at a report in today’s Courier Mail which points out that, as you have correctly shown in the budget here, the money put into improving elective surgery has certainly done a good job. Forty-one thousand additional patients had elective surgery by the end of 2008, according to the budget statement. Yet there is a story in today’s paper from a quarterly public health performance report tabled in the parliament by the Queensland health minister, pointing out that that is great, and the total number of elective surgery patients in category 1 fell from 412 to 128 in that quarter; the only problem was that the number of patients waiting to get onto the elective surgery waiting list, which is the unpublished list behind the public list, went from 160,000 to 180,582. There were 180,582 people in the quarter waiting to see specialists in outpatients in public hospitals, waiting to get onto the elective surgery waiting list.
Until we get this data consistent, until we are measuring everything, I cannot see that knowing that their elective surgery list is shorter is getting us very far at all. I should find a question here, shouldn’t I, Chair?
CHAIR —I feel as though there is one coming, Senator!
Senator BOYCE —My question to you is: other than the public hospitals report which, as we have discussed, will have 12-month-old data in it, how does the department of health know whether state public hospitals in Australia are doing a better job or a worse job?
Prof. Calder —There is a commitment to collection of elective surgery data through the national healthcare agreements, and through a range of other measures, and we have been starting to collect some of that data. Perhaps Ms Yapp can talk about some of the information we have had to date.
Senator BOYCE —That would be good. Thank you.
Ms Clarke —Under the Elective Surgery Waiting List Reduction Plan, the states and territories are obliged to provide us with quarterly data specific to the plan, and we collate that unit record data into reports. The states are also obliged to produce hospital level reports on similar elective surgery information and publish that on a website.
Senator BOYCE —Do you have a reporting date for each quarter, when it has to be given to you by?
Ms Clarke —Yes, we do. The states will submit the data one month after the end of the quarter.
Senator BOYCE —And the quarters are January to March?
Ms Clarke —March, June, yes.
Senator BOYCE —So you would expect to receive their material by 30 April, would you?
Ms Clarke —Yes.
Senator BOYCE —Thank you.
Ms Clarke —The hospital level reporting is also due two months after the end of the quarter, and then there is a national report provided to AHMC—the ministerial council—and that is published following endorsement on the department’s website.
Senator BOYCE —You are measuring elective surgery waiting lists, or elective surgery throughput. What else?
Ms Clarke —The plan has seven performance indicators assigned to it. Procedures is No. 1.
Senator BOYCE —That is all public hospital procedures?
Ms Clarke —Public hospital elective surgery procedures.
Senator BOYCE —Admissions, in fact.
Ms Clarke —The second indicator is a measure of those people who are taken off the list for other reasons: reasons such as they do not need the surgery or—
Senator BOYCE —They died waiting.
Ms Clarke —the surgery has been declined. The third one relates to the number and percentage of patients seen within the clinically recommended time. The fourth is the median waiting time for the 15 indicator procedures, which includes things like knee, hip and cataract surgery. The fifth is the median waiting time by urgency category. The sixth and seventh are quality and safety measures, which cover adverse events and readmissions to hospital following surgery.
Senator BOYCE —What do you do in administrative and monitoring terms about things like where they say, ‘Well, gee, we’re meeting this criteria,’ but the performance on the other side of that door has worsened? How does the system deal with that?
Prof. Calder —The intention over the program of activity based funding work is to develop a consistent and comprehensive set of indicators. As we have already said, the data that is currently available to us is relatively limited because of the lack of national consistency. That is why the work needs to go on, and the intention is that there will be a comprehensive and consistent set of indicators and measures fully agreed by all states by the end of the program, which is a four-year program.
Senator BOYCE —There is going to be an awful lot of money out there before we get to any accountability from the state hospitals, and we certainly have a lot of indicators that they are not performing. The other thing I wanted to touch on is the section called ‘Qualitative deliverables’, the public hospitals and information program. This is the same material that you are talking about, Mr Eccles—the Institute of Health and Welfare, the COAG Reform Council, the Report on government services and The state of our public hospitals material. That is who will analyse all the information that public hospitals put out through the public hospitals and information program. Is that the same thing?
Mr Eccles —That is what I was referring to—the 40-odd indicators.
Senator BOYCE —The data provided through that program will be analysed and published in reports by AIHW et cetera. Analysed by whom?
Mr Eccles —That is one I might deal with tomorrow, if that is okay, once I speak to the experts. Can you give me a reference?
Senator BOYCE —Page 334. We have this list of very worthwhile bodies—the AIHW, the COAG Reform Council—who will all publish reports, but who will analyse them?
Ms Halton —There is a very complicated chart that I have seen. There is no doubt that each of these bodies will analyse. The issue is who is responsible in respect of, for example, payment type issues, and that depends on which kind of payment it is.
Senator BOYCE —Given that this comes under a heading called ‘Qualitative deliverables’, I am even more concerned that we are not talking about something quite as measurable as payments or number of services. All these people could be doing analysis, but you do need someone who is responsible and accountable.
Ms Halton —Yes, and that is why, as I said, I think this little table will help you. It shows you the payment type and who is actually responsible. That is probably the best way to describe it. This is rightly saying that the AIHW will be publishing the data and some analysis of that data. But in terms of who is responsible for—for example, if it is performance payments—actually recommending whether or not performance payments get made, that would be the COAG Reform Council. I think it is best stuck in a table so you can see it.
Senator BOYCE —Analysis that comes from an independent, or more independent, body is going to have more credibility than, for instance, if the COAG Reform Council were to tell me how fantastically the whole thing is going.
Ms Halton —I find it interesting that you say that, because my view would be that the COAG Reform Council has been set up with the explicit charter of being a completely independent arbiter in some of these areas and literally calling it as they see it. If they do not think that the performance measure in a particular area has been met, it is their job to say, ‘Not met. No payment.’
Senator BOYCE —I will be fascinated to watch that play out, Ms Halton.
Ms Halton —That is the stated intention, and I have to say, knowing the people involved in the COAG Reform Council, I have more than slight confidence that they will be quite tough-minded in those analyses.
Senator BOYCE —I have one overall question and you might like to go through this state by state: are the public hospitals performing better than they were 12 months ago?
Ms Halton —As I think we said earlier on, performance on elective surgery waiting lists is laudable in a number of cases but certainly reassuring in others. Our view would be that the cooperation we have seen, for example, in relation to plans in respect of the subacute care area is really pretty good. We do think that we are starting to see some quite quantifiable steps to greater transparency and, therefore, greater accountability and measurable improvements in performance, as in greater production of elective surgery waiting lists and a greater focus on areas of absolute and clearly agreed deficit—to wit, subacute care. Is it universally rosy? No. That is not what we are saying, but we are saying that there are things that we are seeing now in relation to improved performance which we have not seen before.
Senator BOYCE —As we have gone through, we can find that elective surgery waiting lists are better but specialist outpatient waiting lists are not. Overall, are we really talking about an improvement or are we talking about spots of improvement?
Ms Halton —I think the minister is on the record as saying it takes time for these reform initiatives to really become entrenched, but there are really quite positive initial signs.
Senator BOYCE —What is your view, Ms Halton?
Ms Halton —I think there are pleasing signs.
Senator BOYCE —Thank you.
Ms Halton —’One swallow does not a spring make,’ but I think the swallow is flying in the right direction. I am a well-known advocate for comparability of data and transparency—I have been on that hobbyhorse for many years—and these initiatives which will enable us to genuinely look and compare, both in terms of activity and cost, are absolutely moving us in the right direction.
Senator BOYCE —Thank you.
CHAIR —Any further questions in this area? Senator Williams?
Senator WILLIAMS —In relation to public dental health, which is one of your programs, how do you monitor the success of those programs run by the states? Do you have the same sorts of criteria they must meet?
Ms Hancock —Are you referring to the COAG indicator concerning public dental waiting times?
Senator WILLIAMS —I am referring basically to the lack of public dental health, full stop, in country areas. It is almost impossible at times even to get into a private dental practice. In urban areas there is an average of 55 dentists per 100,000 and in rural and remote areas just 17 dentists per 100,000 people. I notice, being new to this committee, that is one of the areas that you are obviously targeting and I am very keen to see if you are making any headway in that area.
Ms Hancock —The government has a stated intention to start a Commonwealth dental health program. That would provide extra funding to the states and territories for public dental services.
Senator McLucas —You would be aware, Senator, that the government has not been able to progress with that because the Senate—in fact, your vote would have been helpful if it went another way—has insisted on retaining the—
Ms Hancock —Medicare chronic disease dental scheme.
Senator WILLIAMS —I am also aware that the $620 million enhanced primary healthcare program brought in by the previous government has had a lot of success in actions carried out by private dentists. I suppose there are political debates we could have here, but that probably will not get us far.
Senator McLucas —This government is of the view—and your earlier question seemed to concur with this—that we need to invest in public dental services. We cannot afford to do both, and the priority of this government to put the effort into where we know the greatest need exists, and that is in the public dental sector.
Senator WILLIAMS —Isn’t it up to the state governments to run some public dental health? Isn’t that their responsibility in the present form?
Senator McLucas —Some states do fund. I do not know if all do.
Ms Hancock —All states run public dental services.
Senator WILLIAMS —Yes.
Senator McLucas —It is the view of the Commonwealth that we would assist in that work to shift some of those very long lists. You may recall that prior to 1996 the former Labor government had invested in public dental health. A review of that investment was undertaken which showed that there was an enormous impact on waiting lists and the ability for particularly older people and very poor people to get dental treatment that they otherwise just did not get. It is our view that, if we are going to invest in dental, the biggest bang for your buck, so to speak, is going to happen by investing in the public dental sector.
Senator WILLIAMS —Minister, speaking to dentists in Armidale, they were saying the public system was so bad that that was why they endorsed the enhanced primary care program of the previous government, because the private sector was actually carrying out urgent dental work at up to $4,500 for an age pensioner, for example. Obviously that program was brought in because the state public dental system was failing miserably.
Senator McLucas —It is not our view that the best thing is to go around blaming people. It is our view that you look where best your money can be applied to assist the most number of people who are in need, and it is our very clear view, supported by evidence, that if you spend money in the public dental scheme you will get better outcomes and more outcomes.
Senator WILLIAMS —We could probably debate that all night as well.
Senator McLucas —We could.
Senator WILLIAMS —But the point I want to make with this is that we do not even hear of a public dentist in the country area where I live, for example, because we are so short of dentists, who seem to wish to stay in urban areas.
Senator McLucas —We could talk about the previous government not training enough dentists, but then that would be a different argument.
Senator WILLIAMS —It could be.
CHAIR —I am wondering whether, Senator Williams, you would like to hear from Ms Hancock about the indicator that she mentioned when she came to the table.
Senator SIEWERT —I certainly would.
Senator WILLIAMS —That would be good, Chair.
Ms Yapp —One of the outcome indicators under the National Healthcare Agreement is the number of services per thousand population for dental services by public and by private.
CHAIR —Ms Hancock, can you tell us how that is collected? Senator Williams is wanting to know how in his part of the world that kind of outcome is actually assessed. Is that right, Senator Williams?
Senator WILLIAMS —Yes, exactly, Chair.
Ms Yapp —As Mr Eccles indicated, discussions were going on today, in fact, as to how exactly all of the arrangements are being put in place so that that information can be collected in a consistent way.
Ms Halton —On that basis, we might take that question on notice, on the assumption that they have resolved a number of those issues, and certainly if they did not resolve them today they will resolve them in the fairly near future. As soon as we have got that, we will give it to you on notice.
Senator WILLIAMS —Referring to dentistry, I have highlighted the lack of dentists in rural and remote areas. You would be familiar with the RAMU Scholarship Scheme introduced by the previous government for training country people in medicine.
Ms Halton —Yes.
Senator WILLIAMS —Wouldn’t a similar scheme in dentistry be very effective, because something like 93 per cent of those country students who study medicine return to a country area, without them being on bonded scholarships or anything like that. Wouldn’t a similar scheme in dentistry for rural dentists have the same effect?
Prof. Calder —In the budget, there was a measure that consolidated a range of scholarships for allied health training to achieve just that—to allow a three-year planning timetable to be used to identify scholarship targeting to areas and professions in need.
Ms Halton —Which would include dentists.
Senator WILLIAMS —Do you know how many positions were available for dentistry?
Prof. Calder —I do not have the numbers with me.
Senator WILLIAMS —Would you be able to get them for me?
Prof. Calder —In health workforce capacity tomorrow you might be able to ask that question.
CHAIR —Outcome 12, Senator Williams.
Prof. Calder —But definitely it will allow more dentists to be trained through that scholarship program.
Senator WILLIAMS —Very good. That is it for me, thanks, Chair.
Senator BOYCE —I have a couple of questions—and whether they get answered here or in outcome 10, I am not sure—around the public dental services. The government is projecting an extra 166,500 dental visits in 2009-10. Could you give me a sense of how many dentists are going to be required to do an extra 166,500 visits?
Ms Hancock —That is under the Commonwealth Dental Health Program, assuming it does commence in 2009-10.
Senator BOYCE —There is a key performance indicator for it in the PBS on page 336. It says that the budget target for 2009-10 is 166,500. It does have the caveat on it that it is based on one million over three years, but this is the best guess of what is going to happen. I presume, given that it is the best guess in the budget, that someone has worked out how many dentists it takes to do that.
Ms Hancock —The states and territories provide these services through their public dental services. They had developed implementation plans by jurisdiction, and each jurisdiction had committed to provide a certain number of services per year for the three years of the Commonwealth Dental Health Program. Those states that needed additional workforce in order to provide those services had included that as part of how they intended to spend their allocation under the program.
Senator BOYCE —Do we still have an answer to that question of how many dentists it would take to do 166,500 extra consultations?
Ms Halton —Not that we have. It was in the state based plans, all of which are different, because this was to be administered by the states.
Senator BOYCE —I realise that.
Ms Halton —But we can go away and have a look to see if there is information that we can glean from those and, if we can—
Senator BOYCE —But I presume that before the state based plans were approved by the department or by COAG—who approved them?
Ms Halton —The minister.
Senator BOYCE —The plans presumably were looked at to see if they covered whether the workforce was available to carry out the other statements in it.
Ms Hancock —Each state undertook to provide its services, and it is the responsibility of each state to ensure that they had the workforce necessary to deliver those. Some states I do recall had, for example, made provision as part of the spending of their allocation under the program to employ extra dentists.
Senator BOYCE —Could we have a list or a breakdown of the one million and the targets for each of those years state by state, please, Ms Hancock?
Ms Hancock —Target number of services state by state?
Senator BOYCE —Yes. What adds up to 166,500 and 333,000 each year.
Ms Hancock —Certainly.
Senator BOYCE —What each state is proposing that it would do would be good. Thank you.
Senator SIEWERT —I am not sure if I should be asking this here or in another outcome. Have you done any assessment on the teen dental program yet? It has only been running for a short time, so you may not be able to answer that question. Could you tell me what the uptake of it has been and what the expenditure to date has been?
Ms Hancock —Expenditure to date—that is, from 1 July 2008 to 30 April 2009—is $57,906,088. That has provided 400,220 services.
Senator SIEWERT —Could you tell me the spread of those services around Australia?
Ms Hancock —I do not have the number of services by state with me, but the spend by state is: ACT $0.59 million; Northern Territory $1.8 million; Tasmania $0.78 million; Western Australia $3.5 million; South Australia $2.6 million; Queensland $11.5 million; Victoria $16.8 million; New South Wales $22 million.
Senator SIEWERT —If you could take on notice the number of services in each of those states, it would be appreciated. Could you tell me what the budget is for this year, please?
Ms Hancock —For 2008-09 or for 2009-10?
Senator SIEWERT —How much do we have left for this financial year?
Ms Hancock —The estimate for 2008-09 is $92.8 million.
Senator SIEWERT —So basically there are three months to go in the financial year from when you gave me the figures, aren’t there?
Ms Hancock —Yes.
Senator SIEWERT —Yes. What about 2009-10?
Ms Hancock —The estimate for 2009-10 is $104.1 million.
Senator SIEWERT —Thank you. Has there been any feedback on the major issues and has there been then referral on for further work through the teen dental program?
Ms Hancock —We have not done the analysis of issues to which you refer. There is an obligation in the legislation which sets up the Medicare Teen Dental Plan—the Dental Benefits Act—to review the operation of the act as soon as possible after its first full year of operation. That means as soon as possible after 1 July this year.
Senator SIEWERT —What is the plan for undertaking that review?
Ms Hancock —The legislation sets out a requirement to appoint a panel of five members and to report, which must be tabled in parliament.
Senator SIEWERT —Yes. What I am asking, though, is: what is your plan to implement that? The legislation says ‘as soon as possible’?
Ms Hancock —Yes.
Senator SIEWERT —So are you planning that already and what is your time line for ‘as soon as possible’?
Ms Hancock —We plan to commence the review in July or August. The panel appointed to the review will obviously have views about the time frames within which the report is presented to the minister.
Senator SIEWERT —You can’t tell me what those time lines are?
Ms Hancock —Not yet.
Senator SIEWERT —Are you providing those parameters to the panel in terms of when you expect a report to be finalised so that you can give it to the minister?
Ms Hancock —We will be consulting with the minister as to her intentions.
Senator SIEWERT —But you haven’t done that yet?
Ms Hancock —No.
Senator SIEWERT —Thank you.
CHAIR —Any further questions in this area? On that basis, we can move on to medical indemnity. Any questions on medical indemnity? Nothing. Nothing about midwives? What about blood and organ donation services?
Senator CORMANN —Yes, I have a few questions. Is this where we can ask questions about the Organ and Tissue Donation and Transplantation Authority as well as the blood tax and these sorts of things?
Ms Halton —We have two agencies at the end of this item. The order we had them was the National Blood Authority, to be followed by organ and tissue donation.
Senator CORMANN —Yes. I seek your guidance, but I do not think that last time the questions on the blood tax were dealt with by the Blood Authority as such, were they?
Ms Halton —No. They were departmental officers. That is the New South Wales issue?
Senator CORMANN —Yes, that is right.
Ms Halton —Yes.
Senator CORMANN —I would just like to explore that a bit more and then I would like to ask some questions about the new authority.
Ms Halton —Yes, that is fine.
Senator CORMANN —Can I do that now?
Ms Halton —You can. The officers are coming from the back of the room.
CHAIR —Ms Halton, we may have some questions on indemnity, but we will do the blood first. We just might be getting these questions on indemnity. So we are going to go into the questions about the New South Wales issue?
Senator CORMANN —Perhaps you could start off by giving us a bit of an update as to where things are at.
Ms Hefford —When we last discussed this we were aware that the New South Wales government had introduced and passed a piece of legislation that empowered the health department—the director-general of health in New South Wales—to introduce a charge for blood and blood products in private hospitals, but had prescribed very carefully that such charges could not apply to individual patients.
Senator CORMANN —So they are being covered by private hospitals, in fact?
Ms Hefford —In some way.
Senator CORMANN —Who else is covering the cost, other than hospitals, if patients are not?
Ms Hefford —At this stage we understand New South Wales has not managed to implement these arrangements. They initially indicated an implementation date of 1 April but have been, we understand, in negotiation with the private hospital sector in New South Wales and have not yet managed to find a mechanism for billing, invoicing and collecting a tax or charge of this kind. At this stage there are no administrative arrangements in place and I am afraid there is very little we can say about that.
Senator CORMANN —Thank you very much for that. You would appreciate that I am very much interested in the federal aspects of this, and you will recall that Minister Roxon expressed serious concern about what emerged out of New South Wales—a concern that we, from an opposition point of view, shared. As I understand it, the minister wrote to the New South Wales Minister for Health, Mr Della Bosca. Did the minister receive an answer to that letter, and what are the indications that we have been getting out of New South Wales in response to the minister’s representations on the matter?
Ms Halton —It is a bit hard for us to talk about correspondence to the minister.
—Sorry. I am not trying to be inappropriate. I am not trying to be smart. I guess what I am trying to understand is that the minister made it public that she had written—
Ms Halton —Yes, she did.
Senator CORMANN —to the New South Wales Minister for Health. To the extent that you can share with us—
Ms Halton —There is an ongoing dialogue.
Senator CORMANN —can you perhaps give us the flavour for how the ongoing dialogue is developing?
Ms Hefford —The Commonwealth and Minister Roxon have, I think, taken the opportunity on a number of occasions to express strongly their concerns.
Senator CORMANN —So the minister remains concerned to the same degree as she was concerned—
Ms Halton —Yes.
Ms Hefford —Absolutely.
Senator CORMANN —So the Commonwealth continues to pursue steps to see that this measure of the state government in New South Wales does not proceed.
Ms Hefford —Correct. And New South Wales continues to try to explore ways of implementing the arrangement, but has not yet managed to achieve this.
Senator CORMANN —I hope that you take this in the spirit in which I am trying to ask these questions. I did have a bit of an exchange, I think with Ms Murnane, last time. She is no longer responsible for this?
Ms Halton —She is, but she is swine-fluing.
Senator CORMANN —That is okay. I am very happy with the answers we are getting. One of the questions that I asked Ms Murnane was whether the Commonwealth had the power to legislate to prevent the New South Wales government from imposing a charge on private hospitals for the provision of blood services—blood and blood products. The answer I was given on the day was, ‘We prefer not to go down that path.’ I totally understand that. The government prefers to work cooperatively with state governments, rather than to come down with the heavy hand of legislating. However, I said, ‘If it’s required, would we have the power? Can you please take this on notice?’ The department duly took that question on notice, and the answer I got back on notice was exactly the same answer I got here during the estimates, which was that the Commonwealth’s strong preference is to resolve this issue by discussion and agreement with New South Wales, consistent with the collaborative nature of the National Blood Agreement, rather than to take unilateral legislative action.
Ms Halton —I think the answer is that it is unclear as to what the power might be. We are getting into an area which is untested.
Senator CORMANN —But have you sought advice? And is there the possibility that the Commonwealth could take legal action to prevent New South Wales from proceeding if that were required? I appreciate and support the proposition that the strong preference should be to resolve these issues by discussion and agreement but, should it be required, what options does the Commonwealth have to ultimately prevent this from going ahead?
Ms Halton —My lawyer, who is probably best placed to answer that question with all its complexities, has gone. I think he may be otherwise engaged. No, here he is.
Mr Reid —The question, as I understand it, is: does the Commonwealth have the power to legislate to stop New South Wales imposing charges for blood? That is not a question we have sought advice about. It is likely that the Commonwealth has legislative power to legislate to do that, but—
Senator CORMANN —Sorry, say that again. It is likely?
Mr Reid —It is likely that the Commonwealth has the legislative power to legislate to do that, but it is not a subject we have sought advice from Attorney-General’s on.
Senator CORMANN —For my purposes—and hopefully for the purposes of the government as well—could you perhaps elaborate on that, having considered the question? I am putting this on notice in good faith. Last time when I put it on notice I was not entirely satisfied that the answer that I got back was actually the answer to my question. I understand your position is that your strong preference is to resolve these issues by discussion and agreement, but can you please outline for me on notice whether and how the Commonwealth would have legislative powers to prevent New South Wales from proceeding with this tax on blood, should it be required?
Ms Halton —We will do that. I think the reality is, though, that because this would be highly contested what I think is being indicated is that we may have an internal view but we have not taken any other advice more broadly across government. Then the question is of the robustness of such legislation and whether is open as to challenge, I think. So we can give you our view, but I am not saying that it would necessarily withstand scrutiny.
Senator CORMANN —Let me put it this way. In terms of having discussions and seeking to reach agreement with New South Wales, presumably if the ultimate alternative option is legislative action by the Commonwealth that strengthens your bargaining position somewhat, I would have thought it would be something that you at least might want to be able to wave around—
Ms Halton —And that is absolutely the issue for the minister to consider in the discussion, yes.
Senator CORMANN —I guess if I can just, again, put on—
Ms Halton —That is fine.
Senator CORMANN —As part of our ongoing conversation on this.
Ms Halton —Yes.
Senator CORMANN —Moving on to another matter within the blood donations area, the minister has outlined that there will be a $1.5 million review of the national blood arrangements which was announced on budget night. Are there any terms of reference for this?
Ms Hefford —Not as yet.
Senator CORMANN —So can you perhaps just talk us through beyond what is in the budget papers to what is planned, what the intentions are and what is going to be involved?
Ms Hefford —Certainly. We acknowledge that pricing costs in the blood sector have been rising in recent years. We also have looked at some of the figures within the department that are available to us. It is quite a complex area.
Senator CORMANN —Yes.
Ms Hefford —What we are identifying when we start looking through the data is that we get variations between jurisdictions either in use of a particular product or in patterns of use, and there is no clear or easy or simple answer apparent to us about how you will identify what the key cost drivers are and what it is that is actually driving demand in this area. We would plan to perhaps have more than one piece of review work—perhaps one that tries to look at cost drivers, perhaps another that tends to look at usage patterns and clinical aspects of treatment—because we need to bring together a number of different areas and consider the way in which these might impact on each other. It would not be useful to look at one aspect of that work in isolation, because you would be perhaps sending the wrong message, either to the many thousands of blood donors in Australia or to clinicians, or you may be adversely affecting treatment patterns, and we would not want to see any of those things eventuate. So it is possibly two or three pieces of work, and the work of scoping those out is something that we still need to do.
Senator CORMANN —So there would potentially be two or three subreviews of a broader review. When do you expect that you would finalise terms of reference for either all or, if they are in a sequence, the first part of the review?
Ms Hefford —We have had some initial discussions with our state and territory colleagues just in the last week and we have talked about producing a scoping paper, which would in effect be something we would send out to all state and territory health authorities through the JBC—the Joint Blood Committee—network, looking to see if we cannot get some agreement about what the broad headings are and clumping the issues under those broad headings. We would be hoping to do that during June-July so that we are probably ready to move forward with a review process in August-September.
Senator CORMANN —This year?
Ms Hefford —Yes.
Senator CORMANN —Have you made a decision on who would undertake this review?
Ms Hefford —No, we have not done any of that detailed analysis. We have been waiting until we have got this broad agreement about what the questions were and how the issues clump together.
Senator CORMANN —So that would be a discussion for a later date. The initiative on page 324 of the portfolio budget statements:
In conjunction with the states and territories, the Australian Government will provide funding for projects to improve transfusion appropriateness, reduce wastage and deliver better outcomes for patients.
In relation to the use of blood and blood products, what, if any, projects have been discussed in regard to improving transfusion appropriateness, reducing wastage and delivering better outcomes for patients?
Ms Hefford —A few moments ago I was talking about the variations we get when we look at usage patterns across the country. Some jurisdictions have introduced patient transfusion medicine services, so they have specialised clinical staff, nurses or other staff who are on hand in clinical settings and who are able to provide clinicians with advice. They are often able to provide clinicians with advice about better treatment or treatment that is not likely to involve so much wastage.
The results from that type of practice seem to be quite good, but because states and territories have introduced such arrangements in different ways, in some jurisdictions they operate in metropolitan hospitals, in others they operate in public hospitals but not private hospitals. It is very difficult to get a clear understanding of a pattern. Again it goes to that issue of trying to work out what are clinical treatment issues that are impacting on patients, what are separately the issues about cost drivers and trying to get some understanding of how they interact.
Senator CORMANN —In the portfolio budget statements all the states and territories are mentioned as being involved. Given that more than half of the surgery takes place in the private sector, will there be an involvement of the private sector? Are you anticipating that there will be funding for projects in the private sector to improve transfusion appropriateness, reduce wastage and deliver better outcomes for patients?
Ms Hefford —Clinical management of patients for blood products is not usually segmented across sectors. The arrangements are that all patients in Australia have access to blood and blood products freely.
Senator CORMANN —Yes, that is right.
Ms Hefford —Clinical judgment is the determining factor in when a patient needs particular treatment and when that patient needs treatment involving blood and blood products.
Senator CORMANN —How much funding is allocated to this particular measure?
Dr Turner —I think a number of the programs that Jenny referred to are undertaken by the National Blood Authority which, under the guidance of the Jurisdictional Blood Committee, engages in a number of activities to improve the appropriateness of blood usage. In relation to the involvement of the private sector, as Ms Hefford said, they involve all parties. For example, one of the programs that has been running for a couple of years now is the National Haemovigilance Program, which looks at adverse reactions to blood products in hospitals, and how we might introduce that. The working party that has formulated that program certainly has involvement from the private sector.
Senator CORMANN —Sorry, can I just interrupt you there, Dr Turner. You are talking about programs that are already running and things that are already underway and how they are managed, and that is all great. I am confident that you are doing an outstanding job with all of that. But I am referring specifically to the paragraph here on page 324—it is in the third paragraph—where it says:
In conjunction with the states and territories, the Australian Government will provide funding for projects—
projects, not programs—
to improve transfusion appropriateness, reduce wastage and deliver better outcomes for patients.
I am trying to get a handle of what sorts of projects we are talking about, what sort of funding is attracted to those projects and are these going to be projects essentially for state and territory governments or across the public and private sectors? What sorts of projects are we talking about?
Dr Turner —Under the national blood arrangements, the Commonwealth provides 63 per cent of the funding. The remainder of the funding is produced by the states, which is 37 per cent.
Senator CORMANN —How much is that in dollars, Dr Turner?
Dr Turner —The overall budget for the production of blood products for 2009-10 is $880 million. I cannot tell you how much of that is specifically for programs. Most of that is for the supply of products.
Senator CORMANN —This is what I am trying to track down. Perhaps you might have to take it on notice.
Dr Turner —I certainly will.
Senator CORMANN —The question is specifically: how much funding will be made available out of the total allocation for the projects that are mentioned here to improve transfusion appropriateness, reduce wastage and deliver better outcomes for patients? Where will those projects be located? What sorts of projects are we talking about? Is that something that you would have to take on notice?
Dr Turner —I will take the funding on notice, certainly. I could give you a few more details about the sorts of programs.
Senator CORMANN —That would be great. Projects or programs?
Dr Turner —Projects.
Senator CORMANN —Maybe I am wrong, but the way I understand it is that a program is something that is a bit more long term and ongoing, whereas a project is something that could be a one-off. Am I wrong?
Dr Turner —No, I would agree with the general definition. For example, one of the projects is the development of new guidelines to guide the use of fresh blood products. That is a three- to four-year project which is being funded through these arrangements under the guidance of the National Health and Medical Research Council. The day-to-day management is by the NBA with involvement from the jurisdictions, including the Commonwealth. They will produce new clinical guidelines which are up to date with best clinical practice to again help ensure that use of products is appropriate.
There are some other initiatives that are starting in relation to education. Funding has been agreed to be provided to one state to improve a program that they run, which is available nationally, to improve the education of practitioners working in the blood area. There is another project which is under consideration which will be funded. There are other programs which relate to improving communications with practitioners working in that area. For example, last year funding was given to bring together transfusion specialists to exchange information and best practice programs, and also the materials that they produce. With some of the initiatives that Jenny talked about, where states are doing very good work, the idea is to bring all those people together so that they can then share the knowledge and understanding. We have another project going which is looking at where and how red cells are used and whether we can use the experiences of one state to provide national data on where people use those products, so we know where we can better target wastage reduction programs.
Senator CORMANN —It sounds like a whole series of very worthwhile projects, but you are going to get me a more detailed list on notice—
Dr Turner —On the expenditure, absolutely—happy to do that.
Senator CORMANN —On the expenditure in relation to all these projects?
Dr Turner —Yes, happy to do that.
Senator CORMANN —If you can perhaps also provide me on notice information on how these projects will be developed and who will be involved, that will be very useful. Listening to the projects that you have just listed, I assume that you are having pretty broad involvement across all aspects of, if I can call it this, the blood sector.
Dr Turner —Absolutely. It is one of the characteristics of the projects that we try and involve as many relevant people as we can. For example, the project to develop guidelines is chaired by the Australian and New Zealand Society of Blood Transfusion. They are taking carriage of that, and we have about 12 clinicians from around the country who are involved in the technical and clinical development of that project. We have been very impressed by the enthusiasm and buy-in of people working in the clinical area to participate in these types of projects.
Senator CORMANN —Thank you very much for that, Dr Turner and Ms Hefford. I do not have any more questions on blood. I have others.
CHAIR —What other questions do you have?
Senator CORMANN —I have questions on the Australian Organ and Tissue Donation and Transplantation Authority.
CHAIR —I will just check that we only have questions on blood from Senator Adams. Is that right? Anyone else? No? Do you have any other questions, Senator Siewert? You are not going to go back to indemnity?
Senator SIEWERT —I do want to go to indemnity, yes.
CHAIR —Okay. Senator Adams, go ahead with your blood.
Senator ADAMS —Thank you. I might need some more soon! I would like to ask some questions about the new blood manufacturing site that is being built in Melbourne to provide blood supplies to all of Victoria and Tasmania.
Dr Turner —Yes, certainly. What would you like to know?
Senator ADAMS —Then I will move on to something from your area, as well. What company is going to do the manufacturing there? What is the set-up with this new—
Dr Turner —All the manufacture of fresh blood products is done by the Australian Red Cross Blood Service, and the proposal is for them to relocate their current facility. They are currently manufacturing out of a facility in South Bank which they have to vacate. So the funding is to build them a new facility in Melbourne to continue the work that they do at the moment.
Senator ADAMS —Where does CSL Ltd fit into this scenario?
Dr Turner —The Red Cross Blood Service manufactures fresh blood products. So they take blood that is donated by people and they manufacture it into red cells, platelets and a number of other fresh blood products, such as fresh frozen plasma. The plasma that is collected is then taken to CSL in Melbourne and is manufactured into a range of other products. These products have a much longer shelf life and they are manufactured in CSL’s Broadmeadows facility. The sorts of products that are produced by them include albumin, intravenous immunoglobulins, some of the hyperimmune products and some clotting factors.
Senator ADAMS —Do CSL have a tender structure, or how do they provide the service?
Dr Turner —They provide it under a contract, which the NBA manages on behalf of all Australian governments.
Senator ADAMS —I note on page 626 of the PBS under, ‘The supply of blood and blood products,’ that one of your performance indicators is:
- Continue and improve plasma fractionation and product distribution by concluding a new contract with CSL Limited.
Was that contract open to anyone else or was it a closed process?
Dr Turner —No. The contract is with CSL, under current government policy. Under current government policy, plasma fractionation is limited to fractionation within Australia, and CSL is the only company that operates in that space.
Senator ADAMS —Have any other companies applied to operate or set up a new business?
Dr Turner —Not to my knowledge.
Senator ADAMS —Is there any area that they can do that? How do you know that you are getting the right price in this market?
Dr Turner —When the National Blood Authority approaches its negotiations with CSL we spend a lot of time and effort understanding the global market and do a considerable amount of benchmarking, so that when we negotiate with them we have a very good understanding of what are reasonable prices in a global context for the production of these products. I would be reasonably confident that we are getting now very good value for money.
Senator ADAMS —If another company or companies decided that they wanted to get into the market, would there be any opening for them?
Dr Turner —That would be a matter for government to decide.
Senator ADAMS —I am aware that the Broadmeadows plant has gone out of service on a number of occasions. Is this plant being upgraded as well, or what happens if it goes out completely? How do we get on with the supply of plasma?
Dr Turner —I am not aware it has gone out of service, except in a planned way. They usually shut down the facility in January for a general service and, because that is planned, we and CSL make sure there is sufficient product in the system that that does not have an impact on the supply of products. One of the roles of the NBA is to ensure supply security, so we have a number of contingency measures in all of our contracts that would apply if, for example, CSL had a problem with their manufacturing. For example, if they were unable to supply us with a particular product, under the contract we have with them they would actually be required to produce product from one of their overseas facilities. That would be one contingency measure. There are a number of measures in place. We make sure we have a comprehensive risk analysis sitting behind the contract and, as I said, we have a number of measures and ways that we can secure supply if they were to have a problem.
Senator ADAMS —That is good. That has answered my questions, I think. Thank you.
Dr Turner —You are welcome.
CHAIR —Is that the end of blood then? What we might do is go to indemnity, have those questions, and then finish up with transplants, if that is okay? Down to you, Senator Siewert.
Senator SIEWERT —Thank you. I am just following up the issues around indemnity. The government has made some announcements around indemnity for midwives.
Prof. Calder —Yes.
Senator SIEWERT —Could you give me a bit of the detail on that? I will tell you the background, although you are probably aware of the background. There are a number of us who are getting letters about home births and indemnity around home births and the way the new registration process will impact on home births. It is not my portfolio area, but I know it is an issue. My colleague cannot be here, so I just thought I would follow the issue up.
Prof. Calder —Yes, the government has announced that there will be supported professional indemnity insurance for midwives. I will ask Ms Hancock to give you the details of that.
Ms Hancock —The government has announced that there will be supported professional indemnity insurance for midwives and that it is the government’s intention that that cover not extend to planned home births at this stage.
Senator SIEWERT —Is that not going to be developing into quite a significant issue, where midwives doing home births are not going to have the cover? The issue that has been put to us is that, therefore, there will not be midwives available for home births?
Ms Hancock —There is no indemnity insurance for midwives doing home births currently available. Home births will not be illegal following the introduction of the insurance cover from 1 July 2010, but the insurance cover will not cover planned home births.
Senator SIEWERT —So there is no intention of the government to extend that or deal with that issue?
Ms Hancock —The government has announced that it is not intending to provide support for home births at this stage.
Senator SIEWERT —Thank you.
CHAIR —Senator Adams, do you have any questions?
Senator ADAMS —I do, on that one. Being an ex-midwife, I am very sorry that they will not allow women to have a choice of home birthing. If you are a midwife and you cannot be indemnified, I do not think you would be taking the risk to do that. I know a number of them have had their own private insurance, but hopefully the government will relook at this. Could you tell me what the expected annual cost of indemnity insurance will be for the midwives?
Ms Hancock —It is expected that the cost of the premium for a midwife will be around $7,500.
Senator ADAMS —I suppose if it is a private one it would cover them for quite a sizeable amount of money, but seeing they are working within the hospital set-up that is a bit different.
Prof. Calder —It is roughly comparable to the level provided for doctors under the premium arrangement.
Senator SIEWERT —Chair, could I cheat: since Ms Hancock is here, I have thought of another dental question on the teen program. I am always pushing the envelope!
CHAIR —It is extraordinarily fortunate that Queensland won.
Senator SIEWERT —Here we go again!
Ms Halton —I do not think she could be bought, Senator Moore—I am really worried about that!
Senator SIEWERT —You have taken on notice to provide the numbers against the states. I am wondering if it is possible to provide a regional breakdown. I am interested in rural or non-metropolitan versus metro, if you have got that level of detail.
Ms Hancock —I do not believe we do. The states were required to commit to providing, between them, around a million additional visits over the course of the three-year program, and states simply have not incorporated, by and large, in their implementation plans the detailed breakdown of location of service delivery.
Senator SIEWERT —Okay.
CHAIR —Thank you, officers. I do appreciate the fact that you came back.