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Tuesday, 1 November 2011
Page: 12374


Mr LAMING (Bowman) (20:18): In the time allowed this evening I would like to make some observations about a bill that has the support of the coalition but, within that, we have a significant number of concerns about a government that has been fixated on creating new bureaucracies and authorities and at the same time has not been engaging in the difficult, grafting, adaptive work that is required to keep a health system running efficiently and effectively.

Around the world governments are focusing on quality and access in health care, and an authority is not a new conception—already, northern European economies have moved in that direction, partly driven by the need to depoliticise a lot of decisions around health care. I think here in Canberra we accept that state jurisdictions are often faced with those impossible asks of delivering perfect care every second of every day all year, and complaints can rapidly find themselves in the mainstream press with a demand for 'action' by ministers. The result has been a larger and larger bureaucracy in the main, asking more people who are not clinicians to constantly be taking a risk-averse approach to make sure 'that never happens again'. So the health authority is an effort to move away from that and to focus purely on quality of delivery. It has been a preoccupation for Western and leading health economies, and behind that has been a shift away from the global or envelope budget for health services towards activity based funding.

Here in Australia we have the Australian refined diagnostic groups—an effort to identify, both with day surgery admissions and even presentations to casualty, a way of paying for great outcomes. That means that if patients are seen and treated properly and if adverse outcomes like readmission to hospital, hospital infection rates or other detrimental outcomes occur, payments are balanced accordingly. We are trying to unshackle clinicians who are at the face of service provision so as to be able to use their ingenuity, skill and training to deliver world-class care. The alternatives, of course, are those risk-averse bean counters who are fearful of trading beyond the funding envelope and will do everything possible to make sure that no risks are taken and nothing new is tried. Somewhere in the middle is the challenge that all of us face.

I have said before that we have large public hospitals that are publicly owned, that are taxpayer funded, that are capacity constrained, and the faster they work the quicker they go broke. That is completely different to the private system where, in a world of item numbers, the faster you work the richer you get. In Australia, with these two impressive elements to the health system, we have to find a way where we do not have cost shifting or gaps left behind. The answer there is to look at those elements—and mental health is one of them—where there is inadequate compensation, to look at areas where the workforce is inadequate, and to address them. That has been a focus of exquisite attention for both sides of this House.

But at the moment the preoccupation is to establish new bureaucracies at exactly the same time that we are not doing what we need to do in basic clinical care. So clinicians are not having their creativity unshackled in hospitals; there has not been a move to genuine hospital boards that are staffed by clinical experts in their fields; and the move to health and hospital reform at state level is—dare I say it—a battered, pale, almost withered form of what was originally posed by this government just three years ago. The reality of getting it through the states means that what we have are three new authorities, each of them in the vicinity of $50 million a year to run, when many of these decisions are quite easily made and are already being made in jurisdictions. Congratulations to South Australia and to the Victorian government, who already predominantly use activity based funding to run their health systems. In fact, all jurisdictions have an element of it, and there is no problem with bringing it together into a federal approach, but the enormous cost that is being incurred by this government in the absence of any other reform is of incredible concern. My comments tonight will focus around cost shifting and cross-border concerns. That is where we see irrational, perverse behaviour by states in response to a very attractive Commonwealth-funded private system that operates in parallel. The great concern of cost shifting is no better seen than in large hospitals that operate with large, coexisting private service providers nearby. We know well that public patients are funnelled across into the private system to take the burden off a public hospital. But when you look at the legislation for this authority, it is almost silent on what can be done apart from noting it, apart from writing a report to the relevant health ministers. The great fear here is that many of these reports are not even made public. You would think there would be enormous public interest in releasing the findings of the independent pricing authority for public viewing. There is potentially some fear of telling the truth—I can understand that may exist in health—but our health system can only benefit by revealing true performance, by being honest about what can be done and what cannot be done well.

In my capacity of looking after rural health, there is no greater and no more acute debate than what can be done in a small hospital, sometimes with a shrinking population or sometimes unable to attract the medical and clinical workforce it needs for a young population that may be moving to the area for mining or agriculture or other enterprises. Queensland is a great example of that. The challenge that we have now—and I raise this because of its relevance to pricing—is that we have had a proud tradition of public and private health operating together. We have accepted that in the public system you may wait a little longer for that dicky knee to be repaired or a little longer for that cataract to be operated upon, but we know when it is done, it is done by the best hands in the land.

The problem or the dilemma we face now is that it is not in the quality of the treatment, but in the availability of the investigations that is holding us back. If you live in a regional city like Rockhampton, Bundaberg or Gladstone and you need a gastroscopy—let us use Bundaberg as an example—you are dutifully as a public patient placed on a waiting list for a two-monthly visit from Brisbane. You may have gastric bleeding and the risk of a cancer, but you will sit on that waiting list. Everything is booked out for two months, and you are lucky if you get on in four months, but more likely six months for that gastroscopy. For all the recordings that are performed by health systems, that is simply a person who has fulminant and metastatic cancer six months later when they finally get their gastroscope. They could have had the investigation six months ago and been treated, but instead they are picked up as a cancer patient and treated just the same as a private patient. It is true they get the same treatment, but the delay in the treatment cost them their life. We do not measure that; we simply measure that someone got a scope and had severe cancer and weeks later received the treatment. We forget the fact that in the private sector they get that scope the following day. They do not even get to that level of metastatic spread; they do not even get to that stage of disease because they are getting immediate access to investigations.

There is the same irrational approach with MRI scans. One single MRI certificate, one single licence, serves three major cities in Queensland. The MRI is in the back of a semitrailer. It spends four days every fortnight in one of those three cities. Here is a private hospital willing to invest in an MRI for this city. What are they told? 'You have to decommission that MRI and not use it for those four days. Transfer the licence across to this MRI that has been put in by the private sector and then let the mobile MRI sit in the dust for four days or let people pay full price to use it.'

These are the elements that we need a government addressing right now, not years away, not back-patting and congratulating themselves for yet another $50 million a year bureaucracy. That is fine, but you simply cannot forfeit the work that has to be done in the areas that could potentially save lives. In bowel cancer screening there should never have been an interruption to that wonderful program, but under this government there was at the start of this year. The program ceased early with no commitment to ongoing funding, and a world-class bowel screening process was held hostage for months in some weird budgetary process. We had to wait until there was a better understanding of where the budget would lie before we could continue bowel cancer screening for Australians.

Cross-border disputes is an area where states can sometimes act irrationally, particularly in mid- to small-size states that do not have the complete array of surgical options available in the capital cities. Tasmania is a good example, but even my state of Queensland, hard as it is to believe, does not have every subspecialist surgeon known to mankind able to do operations with the most recent training from major centres like the US and Europe. Those great surgeons may be in Sydney. Is there a way we can work together as a nation to see that someone is not disadvantaged because of their postcode? Someone who happens to have a four at the front of their postcode cannot see that surgeon who operates publicly at the Prince of Wales Hospital in Sydney. It should be easy: you should put that person on a Sydney list and Queensland Health should simply compensate New South Wales.

The complexity is byzantine. The delays are extraordinary. One constituent from my electorate had to wait more than three months with a progressive vascular disease of the brain, simply because Queensland Health could not bring itself to arrange the transfer. No-one here would support that delay; everyone would want to see a solution. There is nothing convincing in this legislation that tells me this will be fixed. My great concern is the government—with respect, you do not need advice from me—has too much faith and too much trust in bigger and bigger bureaucracies and it is not unlocking the creativity and possibilities within health systems. It needs to unshackle those who know how to run services better and that is going to require a whole lot of political creativity to get accessibility, availability, efficiency and, most importantly of all, quality right. You just need to walk into a public hospital to see how it works. There are plenty of visiting surgeons giving their time—often for fairly low pay, certainly less than it costs to run their private practice—to teach in public hospitals. To all of them we take off our hats. We take off our hats to all of those who work in outpatients and continue those services. The great problem is that part of that honorary role, part of the MO contract, is teaching, research, service development and training. It is very hard to price. Do you want to pay a specialist to see 20 patients and do no teaching or 15 and bring on the new cadre of surgeons and specialists?

Of course we need both. But there are very limited ways to price this in to a system that relies on the cost of doing business two years ago—because that is the most recent health data available. We have an uplift for inflation, we have a slight reduction for efficiency measures, and then we have a market-forces factor where we correct for geographic variations where markets mean that input prices may be slightly different. But, after that, it just requires clinical acumen to work out in an economic sense what the prices are for a range of inputs.

I hope I have outlined what the pricing authority would do. It has already been happening in most jurisdictions for nearly 10 years, but we are yet to move to an element of free pricing where markets can set their own prices for medical services. That is the next great step and the next great reform in this area.