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Community Affairs References Committee
Palliative care in Australia
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Community Affairs References Committee
Moore, Sen Claire
Fierravanti-Wells, Sen Concetta
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Community Affairs References Committee
(Senate-Tuesday, 24 April 2012)
CHAIR (Senator Siewert)
Ms A Smith
Ms C Smith
- CHAIR (Senator Siewert)
Content WindowCommunity Affairs References Committee - 24/04/2012 - Palliative care in Australia
BISHOP, Mr Michael, Life Member, Services for Australian Rural and Remote Allied Health
WELLINGTON, Mr Rod, Chief Executive Officer, Services for Australian Rural and Remote Allied Health
Evidence from Mr Bishop was taken via teleconference—
CHAIR: I welcome the representatives of Services for Australian Rural and Remote Allied Health, SARRAH—which is much easier to say! I know that you have done this before, so I know that you know information about parliamentary privilege and the protection of witnesses and evidence. Do you have anything to say about the capacity in which you appear before the committee?
Mr Bishop : I am a past president of SARRAH. My paid employment is as Director of Allied Health for the Northern Area Health Service in Tasmania, and I am currently representing the Tasmanian group as convenor for SARRAH.
CHAIR: Thank you. We have your submission. It is No. 18. I invite either or both of you to make an opening statement, and you know the pack drill: we will ask you some questions.
Mr Wellington : Thank you, Senator. I will make a brief statement on behalf of SARRAH and then open it up for the committee's questions. Thank you for the opportunity to appear before the committee as a witness. SARRAH, as I think most of the committee members are aware, is nationally recognised as a peak body representing rural and remote allied health professionals working in both the public and the private sector. SARRAH's primary objective is to advocate for, develop and provide services to enable allied health professionals who live and work in rural and remote areas of Australia to confidently and competently carry out their professional duties in providing a variety of health services.
I will not go through the range of health professions that SARRAH represents. It is contained in our submission. In addition, we acknowledge that our submission uses examples of cancer in the palliative care context; however, we acknowledge that palliative care covers all areas of chronic disease.
We are of the view that Australia should be justly proud of its health system, which offers a range of palliative care services. However, these services across the nation are fragmented and not coordinated. I think the committee heard some evidence of that this morning. Access to allied health services by patients requiring palliative care is not adequate, and access is even worse in regional, rural and remote Australia.
The challenges experienced by allied health professions in rural and remote regions to support palliative care patients in their community currently lead to the increased likelihood of admission to institutional care in metropolitan areas. The low home death rates in rural settings may pose particular hardship for rural families who may need to travel extensively or temporarily relocate to be closer to the hospital where their loved one is dying. Those who live in rural or remote areas have additional issues to consider when managing life-limiting complex illnesses. Staff caring for these people also have additional considerations due to their having access to fewer resources.
Patients and families have to manage alongside many challenges, including access to adequate services, transport and time away from home for investigation and treatment. Isolation and loneliness is a real issue for those in rural and remote Australian communities. There is strong evidence about the health, social and economic benefits of the allied health services component in supporting people with chronic and life-threatening illness or disease.
Throughout the paper we have outlined some recommendations. One that is not included in the paper is: 'We are of the view that future government policies need to be rural and remote proofed', for want of a better term. I did have a quick skim through the department's submission earlier this morning, and I noticed that they have specifically afforded three paragraphs out of 50 pages to rural and remote issues.
CHAIR: Just quickly on that: you may not have been here at the beginning of the department's evidence but I did ask them if they could provide us with some further detail on expenditure specifically for palliative care in rural and remote areas.
Mr Wellington : Thank you, Senator. All I was going to say was that that really represents the issues being faced by consumers who require palliative care in rural and remote Australia as well as the lack of allied health services in those settings. Thank you.
Senator MOORE: Mr Wellington, I was going to take up that point. I have actually marked your submission where it says that all services should be 'rural and remote proofed'. This is on page 5 of your submission. What does that mean?
Mr Wellington : I guess what we are talking about in that context is the adequate provision of services and infrastructure so that palliative care services can be provided in those settings as far as it is realistically possible. We are not suggesting that palliative care services will be available in every rural and remote community. What we are suggesting is that there needs to be some consideration given to people who reside in those settings, and we are not sure that at this point full consideration is given to those matters.
Senator MOORE: In your submission you talk about the existing services, of which we have some knowledge, of getting people from allied health services into remote and rural locations and that both of them need to be mentioned, maintained and improved, and also that the Medicare local model should engage with allied health people and not be doctor dominated.
Mr Wellington : Correct.
Senator MOORE: We had a hearing yesterday in Townsville on medical services in regional and rural areas—I think that is what it is called; the 'r's get thrown around. It was being consistently raised that we need to focus on all medical services and not exclusively on the medical profession. That is what you do for us when you come and tell us about things. Your submission talked about personal experience, and one of the areas that were specifically mentioned was dieticians, who often do not get a fair go in the discussions that we have here. Can you give us some indication of why, of all the groups that you represent in this submission, you chose to give us, I think, quite telling and direct comment from people on why it was important to have the support of a dietician throughout their palliative care.
Mr Wellington : Before I ask Michael Bishop to respond to that particular question, I will go back to the workforce support and training programs that are available for our allied health professionals. Whilst we appreciate the level of support that the Commonwealth government does provide, we administer on behalf of the Commonwealth government five scholarship streams across all allied health professions.
That only equates to about $12.5 million a year across Australia. When you look at the support that is provided to GPs and nurses in this country, we are a long way behind the eight ball. Michael, I would invite you to respond to the example of picking up dieticians specifically.
Mr Bishop : My professional background is as an occupational therapist, and I have worked in regional, rural and remote parts of Australia for 20-something years. I have quite a lot of different kinds of experiences that I could talk about. In particular I am concerned about and will use the three different kinds of perspectives. In a regional area, for example, in a provincial centre the issue is that the state government very rarely has adequate resources to provide the support that people need to maintain adequate nutrition from a public sector. Therefore they require the private sector. The current incentives or disincentives for private practice in the provincial areas means that it is very hard for people to access a dietician to maintain adequate nutrition to the end of their life or while they are living. That is part of the issue. It is very hard to access appropriate dietetic resources either from a public sector or from the private sector in our provincial centres.
In a rural area usually in Australia you are relying on an outreach or hub and spoke model where the dietician goes out, primarily from the public sector, and has a visiting service. That can either be coming from a community health or primary health care kind of setting, or from a GP division or what they are going to be calling a Medicare Local.
In the remote setting it is very different. Because of the scarcity of dietetic resources in those areas the dietician requires or uses a population health or a public health approach. It is very hard to get the individual support needed for remote settings.
Although SARRAH has members in each of those areas, in terms of palliative care one of the things that is important is to be able to live until you die. That is why we talk about in our submission about having a rehabilitative kind of approach. We are all dying, so it is very important to live until you die, to live with dignity, to die with dignity and, if you are sick, you need to adequately nourished and adequately hydrated. I was working in private practice as a Department of Veterans' Affairs provider and I can give you an example in the Mackay-Whitsunday area where a remote family were looking for their mother. As people become dehydrated or not nourished properly they can become confused, disoriented, psychotic, all those sorts of things. Therefore, it is very distressing for the family, if they are caring for that person in the home, to see their loved one when they have gone to a lot of effort to keep that person in the home. It is very important. You do not need a dietician all the time but, when you do need one, you need them now; you do not need them in two, three or five days time. The complexity of our system makes it very hard for people in community settings to access adequate dieticians. I hope that answers your query.
Senator MOORE: It has come up in a couple of submissions about the range of need that there is in effective palliative care. Dieticians have been mentioned in a lot of the submissions, yet they are often overlooked. I wanted to give you the chance to make a comment.
Mr Bishop : Under the old divisions of general practice there were a number of programs provided by the Commonwealth to encourage more access to allied health professional services. The funding is very low so the incentive programs for allied health professionals in private practice under that particular scheme are very low. It is very hard to sustain private practice, but it is often the only service that people can get. The general practitioner needs to be aware of what the dietician can offer, and that is part of the problem that we face in that people are not aware of what is available to help people. Also there is not the access once they are aware.
Senator MOORE: I have one more question and I know SARRAH have looked at this. It is the issue of telemedicine and the opportunities, perhaps, for issues such as dietetics to be picked up in some of the regional and remote areas by that form. I see you have mentioned the PCEHR.
Mr Bishop : The PCEHR, yes.
Senator MOORE: You have mentioned that. In terms of the telemedicine, do you have any comments about the way that could be effectively used?
Mr Bishop : SARRAH has done quite a lot of work in examining different model of using telehealth and telemedicine and are very excited about the opportunities that are presented to Australia, which is really leading the world in some of those areas. For example, in terms of allied health research, the University of Queensland is looking at providing clinical decisions, support and telehealth direct clinical care—not providing a phone message with someone on the end of a computer on the internet, but patient care directly over the network. That telerehab process is being done there. That has been trialled in Queensland. It is well evaluated and it works very well. In other areas where there is a relationship between the person and the provider, it also works very well. But unless there is some capacity for the allied health professional or the provider of the services to develop a rapport, it is not as effective.
There are different models around the whole of Australia using allied health assistance, generic health workers, supported by the professionals. Even some of the smaller hospitals are being supported through providing direct services as well as carers. In the Darling Downs area in Queensland they have done a lot of work in supporting people to be supported in palliative care situations using telehealth. The idea is that the funding is not always there. The people also have some problems—although it is much better than it was—in terms of feeling competent in using the internet or telehealth services, although that is changing. It is the way of the future and I think that is very exciting.
The PCEHR—and I have been representing SARRAH and the development of that—has some fantastic opportunities and also some threats for allied health. Due to the economic and other political circumstances around the PCEHR, I believe it will not be what we have been talking about for the last couple of years when it is launched in July. I think it represents some risk to allied health. Because the government has provided incentives to computerised medical practices and developed software for medical practices, they are ready and able to link into the PCEHR. That is not there for the private allied health professional sector, nor is it there for the public sector.
If you are a person with chronic disease or requiring palliative care services, you are likely to see a large number of providers. That might include a dietician, an occupational therapist, a physiotherapist, a doctor, a community nurse, a podiatrist et cetera. If there is no easy way for these people to talk to each other—and you will hear this in the submissions—it can very easily mean duplication or a total loss of important test results that can provide a big impetus to improve someone's care. Test results are not just pathology results or assessment; they can be about social capacity and the sorts of things that will not be captured on our PCEHR. Although it will be the first time in Australia that we have—and I am very excited about it—a really good system that provides potential to link, I do not believe that from July there will be a real ability for allied health professionals to join in that system.
Senator MOORE: Thank you Mr Bishop, I knew that was your position; we have had it before. I just want to let you know that I am from the Darling Downs, so I was very keen to have that unsolicited piece of support in your evidence.
Mr Bishop : I did not know where you were from. Good work!
Senator FIERRAVANTI-WELLS: At page 4 of your submission you refer to the current need for allied health services. You say: 'Allied health services are under-utilised in the current healthcare system, which is effective at channelling people requiring palliative care services into the acute tertiary service system.' Can you expand on that? How could that be rectified?
Mr Bishop : Let me give you an example. If you have a condition that has chronic pain and you are unable to access a physiotherapist, a psychologist or someone who is going to help you manage your chronic pain, where do you go? You go to your GP or to the emergency department of your local hospital—this is in provincial areas or even in rural areas. Once you are in that system, it is very easy to get referral from your GP to a specialist, and then to the next specialist, and then become an inpatient. Our healthcare system in Australia funnels people very quickly from a primary healthcare setting or a community setting into an acute service setting, when really the chronic pain that you might be experiencing could most definitely be seen by someone in your community as an outpatient. That gives you much more power, autonomy or self-management than what happens when you are in that system, which just funnels people in and takes away their autonomy. We under-utilise our allied health professional resources because we do not have options for people to access them other than through the gateways of the general practitioner or the emergency department. Because of the dominance of our model, because the whole system is designed to stream people in and out of hospitals, we waste all this money. It is a sledgehammer approach to something that does not need a sledgehammer. It needs something much more gentle. Does that illustrate my example?
Senator FIERRAVANTI-WELLS: It takes me to the next point. We saw the kerfuffle a couple of years ago with the occupational therapists and the social workers, when there were issues about removing their Medicare rebate for dealing with mental health work. At that time, we saw how much occupational therapists and social workers were doing in that space in the absence of other mental health professionals. So it works both ways. That was a very good example of where, because there were often not those other services, the occupational therapists and the social workers were doing important work, particularly in regional and rural areas. What you are actually saying is that, just like in the mental health space, you could do so much more in the palliative care space.
Mr Bishop : Yes, that is exactly right. There are many instances in terms of mental health—for example, there is a lot of work around Australia amongst the allied health professions—and looking at core competencies around some of those things. It is very different from medicine and nursing. If you think about it, you have got 26 different autonomous professions that are now working together to come up with some core competencies that are supporting rural and remote practices. The work that is done in Western Australia is leading the way. There has been work done in Victoria. There is currently work being done in Tasmania around it. Really, as a group of disparate professions, it is about the difference between stakeholder behaviour and shareholder behaviour.
If you are a stakeholder, you protect your stake against all people who are going to infringe on your territory. Then shareholder behaviour is where you grow the business of health. In rural and remote Australia there is a lot of leadership, a lot of goodwill, from different professions to work together because they are very genuinely and passionately interested in the community they are working in and they want to make a difference. To overcome that stakeholder behaviour work together that once you have already got an established professional career is very exciting and shows why Australia's health system is so fantastic.
Senator FIERRAVANTI-WELLS: You have commented about access to specialised equipment. How does that practically work, not only in rural and regional areas but in remote areas of Australia? You have touched on the difficulties but can you share with us some of those practical difficulties.
Mr Bishop : Yes. For example, if you are going to be caring for someone in their home who is bariatric—an overweight person—you are unlikely to have in your area a specialised bed to move that person and care for them, or a specialised mattress to maintain skin integrity. But you are not going to need that until the person you are caring for, or your loved one, is at a point where they are not mobile or they are going to be cared for at home. They cost a lot of money—$10,000 to $12,000—so you need them to be there when you need them, but you do not need them to be hanging around the rest of the time. In Australia we have a very fragmented and hopeless group of systems in terms of equipment provision across the states. The Commonwealth does get involved through its Department of Veterans' Affairs services and through some of its HACC programs, but each state has a totally different way of providing equipment to support people in palliative care, in disability and in the acute health system. How people can access equipment depends on the way the states run those. So there is money provided by the Commonwealth to support palliative care equipment but that is usually a separate pool of equipment that is managed by the states or by the disability sector. It really is a dog's breakfast.
Mr Wellington : If I could add to that, Michael, Senator Moore raised the point of what is happening in her state, in that access to equipment in some instances is capped at three months but other states have various arrangements. To reinforce what Michael said, it is all over the shop. There is no standardisation: the provision of equipment in some states is insufficient, whilst in others there is no cap.
Mr Bishop : Just an example: if you drive around Tweed Heads, outside nearly every second house there is for sale a motor scooter that has been provided by the government or that has been purchased and that they cannot get rid of, yet there are all these other people who cannot access these. So it is really very fragmented.
CHAIR: I would like to acknowledge former senator Kay Patterson is in the audience. Hello.
Mr Bishop : Hello, Senator Patterson.
CHAIR: I particularly mention that because Senator Patterson has been an active member of the community affairs committee in the past.
Mr Bishop : Senator Patterson knows me from days gone by.
CHAIR: You mentioned in your submission the number of people per year in rural and remote Australia there are with cancer. How many of those end up having to move into the city because they do not get adequate support in their community? Does either of you know?
Mr Bishop : I do not have an exact figure. I chose cancer because it was easy to demonstrate.
CHAIR: I understand.
Mr Bishop : I do not have the figures, but I can give you examples from all the places in Australia where I have worked and I know that people have had to move from.
CHAIR: Would you be able give us a few case examples of that on notice, please?
Mr Bishop : Yes. Do you want them now or do you want me to find out?
CHAIR: Maybe take it on notice—I am clock watching. It would be fantastic if you could take it on notice.
Mr Bishop : I will do that.
CHAIR: This morning we have followed the theme of Medicare Locals a little bit. It was suggested, and you recommended in your submission, which is why I raise it with you:
… that the Commonwealth use the Medicare Locals as a platform to strengthen multiprofessional palliative care services in the bush.
I would like either of you, if you can, to express any experience you have had working with Medicare Locals to try to achieve that and to get Medicare locals to take on board issues around palliative care.
Mr Wellington : I will take that first, Michael, and you can add any additional comments. I did note that and was present in the room when the issue of Medicare locals was raised. In our opinion, Medicare Locals do have a role as part of the population health planning activities they are contracted to undertake. You may be aware of what we have specifically been doing with Medicare locals across the country. At this stage there are 33 Medicare locals that have rural and remote geographical coverage. I personally have been contacting those 33 over a period of time. I must say in defence of the Medicare Locals that they are at various stages, as you can imagine, depending on which tranche they were announced in: tranche 1, 2 or 3. In addition to that, it was quite interesting as part of the call for expressions of interest, the ITR process that the department released a couple of years ago, to see that five, I think, applicants to become Medicare Locals contacted SARRAH directly. That is a bit of a worry. I would have thought there would have been a lot more, but perhaps that really illustrates how GP dominated the system was under the old system with the divisions of general practice. Upon saying that, there are probably three or four, a handful, of the Medicare locals that we are foundation members of. We have been involved in voting on the selection of the board, which is fantastic. But comparatively speaking I am talking about a handful as compared to 33, so we have got a lot of work to do. I acknowledge that it is a two-way street and we are very proactive in terms of maintaining a strategic relationship with those 33 Medicare locals to try and support, for example, allied health professionals who are providing services in those communities.
Mr Bishop : I was so excited about the potential of Medicare locals as an allied health provider and coordinator of services because I thought here were opportunities to create some incentives for the general practice community to see different approaches in managing chronic disease and being able to fill in the gaps in the community where there is real health need. For example, I mentioned bariatric services. There has to be leadership, and I thought that the Medicare locals are a good opportunity. But I support totally what Rod is saying. There is very little incentive for Medicare locals to involve allied health professionals at a given time and SARRAH has limited capacity to be able to actively pursue it. We rely a lot on volunteers to be pushing an allied health view in the Medicare locals but I believe they are a really good hope for Australian people.
CHAIR: I take it from that that you will continue pursuing them.
Mr Bishop : Yes.
CHAIR: In your submission you make comments about allied health professionals needing to be involved in assessment of patients' needs at various stages. Judging from some of the comments you have made, would it be fair to summarise it by saying it is fairly patchy as to what level of involvement allied health professionals are having, particularly in regional and remote circumstances?
Mr Bishop : Yes. I can provide many examples to the committee about that. You do not just need a pathology test or an X-ray; you need a view of the person and their life and how you are able to support that. That is best gained by a multidisciplinary team of people who can provide expertise that is not shared in those areas. In Australia we have taken the very brave step of being able to exercise as professionals without necessarily having a medical referral but encouraging them to work as a team. So if you have got someone you are caring for or you have got a chronic or life-threatening illness or disease, you need to be able to access those people quickly so that you can therefore make decisions about how to live. That is just not accessible properly or responsive in most rural and remote areas at the moment.
Mr Wellington : If I can add to that, the question was posed to Palliative Care Australia before morning tea about case management, for want of a better word.
CHAIR: You are going where I was going to go, but that is fine.
Mr Wellington : The issue was raised about who should lead that case management team. We have a view that it does not necessarily need to be the GP. In some rural and remote settings there may not be a GP, it may be an allied health professional.
Mr Bishop : We have an amazing member from Western Australia who is a dietician who has worked in that community for many years and has a really strong rapport with the Aboriginal people in that community. That person, who has the trust and rapport of those people community, would seem to me to be the most appropriate person to be a case coordinator.
Mr Wellington : Another example, just leading on from that, relation to Aboriginal health workers in remote communities, where there are no GPs. Why shouldn't they be deemed as appropriate case coordinators, particularly given that there are a range of cultural issues that need to be acknowledged?
CHAIR: We have run out of time. You have a little bit of homework. You took a couple of questions on notice. We have a bit of time with this inquiry, so, if you could get us some responses towards the end of May, that would be very much appreciated.
Mr Wellington : Thanks very much.
Mr Bishop : Thank you.