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Community Affairs References Committee
Palliative care in Australia

PARKER, Associate Professor Deborah, Director, University of Queensland/Blue Care Research and Practice Development Centre, Blue Care

ROBINSON, Mrs Marie, Community Care Adviser, Blue Care

Committee met at 08:58

CHAIR ( Senator Siewert ): Welcome. I declare open this public hearing and welcome everyone who is present today. The Senate Community Affairs References Committee is inquiring into palliative care in Australia. Today is the committee's second public hearing for this inquiry. These are public proceedings, although the committee may agree to a request to have evidence heard in camera or may determine that certain evidence should be heard in camera. I remind witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It is unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee and such action may be treated by the Senate as contempt. It is also contempt to give false or misleading evidence to a committee. If a witness objects to answering a question, the witness should state the ground upon which the objection is taken and the committee will determine whether it shall insist on an answer, having regard to the ground that is claimed. If the committee determines to insist on an answer, a witness may then request that the answer be given in camera. Such a request may also be made at any other time.

I welcome our first witnesses. Information on parliamentary privilege and the protection of witnesses and evidence has, I understand, been provided to you. Would you like to add anything about the capacity in which you appear?

Mrs Robinson : I am the community care manager for North Queensland but also I am currently the community adviser for Blue Care in our head office.

CHAIR: We have your very comprehensive submission, No. 28. Thank you for that. I invite either or both of you to make an opening statement and then we will ask you some questions.

Mrs Robinson : Blue Care is one of Australia's largest not-for-profit providers of residential aged and community care. We support community based clients, residents of our aged-care facilities and their families throughout Queensland and northern New South Wales through all stages of palliative care. Results for Blue Care palliative care provided in 2011 show that the number of clients receiving services were from different funding sources as follows. Queensland Health funded palliative service in the community saw 1,228 clients assisted, of which 27 per cent were under 65 years of age. The figure for Home and Community Care, or HACC, funded clients receiving palliative care was 6.2 per cent, of which 27 were also under the age of 65. The number of hours of palliative care actually delivered to community based clients was 234,940.

Through the submission, factors were identified affecting all recipients of palliative care, whether from rural, regional or metropolitan areas. It is the current system of funding and delivery of palliative care, which is reliant on secondary funding through hospitals, that requires reform. In the submission we have tried to provide solutions and recommendations that are both grounded and innovative on how palliative care inadequacies can be overcome. These include the utilisation of technology and increased support of current primary level providers. They could provide improved access to rural and remote settings, reducing travel for clients. Funding overnight respite services will assist in supporting choice for clients with life-limiting illnesses and reduce carers' long-term stress. Difficulty accessing medical services could be improved through adequate funding for services, the provision of after hours care and improved access to specialist medical and clinical phone support. E-learning opportunities, videoconferencing and web based training would increase education accessibility for regional and remote clinicians. We recommend an effective interdisciplinary model of care involving primary care-palliative care providers such as Blue Care and the GP working collaboratively with visiting physicians and dedicated nurses employed by the hospitals. The improved communication would result in a cooperative palliative approach and improve continuity of care for the people that we serve.

There is no specific funding available for early intervention, after hours on-call services or grief recovery programs. End of life services are funded by Queensland Health and managed by the local health service districts. Community care providers, which include not-for-profit providers such as Blue Care, apply to the hospitals for funding when they determine that the person may be entering the terminal stage of their illness and within the last three months of their life. As it is difficult to determine when someone will die, people with life-limiting illnesses often receive significantly less than the allocated three months available; or, occasionally, they just run out of funding at the very end stage of their lives.

The average Blue Care hospital funded palliative admission for 2011 covered only 20 visits, which represented less than three weeks of seven days a week service. At the other end of the scale, where time until death is unpredicted, the client lives longer than the three-month time frame and funding may be ceased. Funding can often be limited to one hour of care per day. However, one nursing visit for an unstable, deteriorating or terminally palliative client can take up to three hours. Personal care, domestic assistance and allied health services and respite support are often not funded.

I will give you an example of a visit to a palliative community client. One nursing visit of an unstable, deteriorating, terminal palliative client can take up to three hours if the following tasks are required: bed sponge, continence care, oral care, pressure area care, symptom management, medication titration, syringe driver change, subcutaneous ketamine change, breakthrough medication preparation, family support and education, and liaising and coordinating with the GP or the palliative specialist team. And that does not include the documentation.

A more accessible, equitable approach to funding community based palliative care is recommended. This funding should be able to be accessed directly by the organisation providing the care rather than brokered through the local hospital and should not be determined by an estimated prognosis. Once a palliative diagnosis is determined, funding could be staged to cover increasing needs and be flexible to incorporate clinical care, including nursing and allied health, after-hours care and lifestyle support. Funding could also include the ability to access time-limiting interventions such as overnight respite services and grief recovery programs. Funding will become even more complex in Queensland, with the introduction of a new structure and a move away from Queensland Health with 16 local area health networks and the solution being that funding be provided directly to the provider. I will hand you over to Deb Parker.

Prof. Parker : My focus is more on residential aged care. For the last 20 years I have worked as a researcher looking at the interface between aged care and palliative care, which includes a national and international research program. I have three extra issues that I want to discuss, which are not in the submission. The first is the workforce, the second is the interface between specialist palliative care services and residential care, and the third is funding under ACFI.

Currently, medical support is provided by GPs, most of whom have limited training in care for older adults or in palliative care. While there are some dedicated GPs who specialise in care of older people, most of the GP support for those people who die in residential care—in 2009-10 there were 30,945—was fairly limited.

Senator BOYCE: That is a national figure?

Prof. Parker : That is a national figure. As we know, some residents die within a short period of admission—24.6 per cent of residents die within six months of admission. It is imperative to get good medical care organised for these residents. I conducted a recent study. I developed and tested an evidence based model of care where GPs were encouraged to attend a palliative care case conference. In that study, approximately 50 per cent of residents who had been identified as having a prognosis of less than six months had a GP come along to one of those palliative care case conferences.

This study specifically focused on the use of case conferences and engaged the GPs with well-organised timeslots, coordinated by the nurses and a clear process to be followed to ensure that time limits were adhered to and that the GPs could claim, using the EPC Medicare items. In this instance, with this support of a well-funded research project, we can achieve the 50 per cent of GPs coming to a palliative care case conference for residents. You can imagine what the norm is when that sort of support is not available. I can tell you that the incidence of getting a GP to come to a residential-care facility to conduct a palliative case conference is almost non-existent. This project showed significant improvements in family satisfaction and resident outcomes.

How feasible is it for us to continue to focus on GPs to provide the level of support that is required for older people in residential care and what are some of the alternatives? One solution I want to propose to the inquiry is to look at the model used in the Netherlands, which is a nursing home doctor model. I would encourage the inquiry to think about a feasibility study of the introduction of a medical specialty in aged-care medicine in residential aged-care, which is different to our current geriatricians. These specialists would be specifically trained and employed in residential aged care. I recently had the privilege of visiting the Department of Nursing Home Medicine, at VU University in Amsterdam. There they use a teaching nursing home model and they provide two-year training, which has been offered in the Netherlands since 1990, when they realised that reliance on GPs for care of their elderly was not adequate. So whilst it is a more expensive model, compared to using GPs, they find that cost savings are realised, with an almost 95 per cent death rate, in the nursing home setting, as opposed to transferring people to acute care, which is what often happens in Australia. My second solution is to also look at the importance of interface between residential aged-care services and specialist palliative care services. I am sure you are aware that specialist palliative care services are administered by the state and residential care is administered by the Commonwealth. People seem to fall through the gaps in residential care. Again the solution is to find dedicated specialist palliative care nurses to support residential aged-care facilities. In Queensland we have a very good service, offered by the Brisbane South Palliative Care Collaborative, where they currently support about 80 residential care facilities in their geographical region, employing 2.6 full-time equivalent palliative care nurses. This is probably not sustainable across Australia. However, I would think that the opportunity to employ a specialist palliative care nurse within each of the major tertiary palliative care services would be feasible, and I think that the recent announcement of funding—I think it was about $21 million out of the Productivity Commission—will go some way towards supporting that, but I have not seen the level of detail of how that might be administered.

The final issue is about funding. Ironically yesterday, 1 July, marked the day when ACFI funding changes in this country and a significant reduction is going to be available to providers like Blue Care. So your mother or father entering a residential aged-care facility today will get funded for less care based on changes predominantly to areas which have great significance to palliative care, and that is hygiene and medication. I will give you an example. If you have a current resident who scores medium for all three domains, they receive a care subsidy of $121.51 per day. If the same resident were admitted today or reclassified, they would score low, medium and low and receive a subsidy of $59.43.

Senator MOORE: I have three lots of questions. Some of these might have to go on notice. The first one is to do with the example that you put in your submission about the North Burnett and Fraser Coast. You said that they were able to provide services despite the current situation with funding—which I take is both state and federal, but specifically state funding on these areas. I would like to get some more detail on record about what is being done differently in North Burnett and Fraser. I take it that is the same area for Blue Care. That is not two separate Blue Care areas, it is one.

Mrs Robinson : It is two separate Blue Care areas.

Senator MOORE: Okay. You have drawn particular attention to that in the submission, saying that is working well. Why?

Mrs Robinson : It was actually a trial to see how it would work.

Senator MOORE: You actually say in your submission that it is working well. I want to know why.

Mrs Robinson : I do not actually work in that area, but to answer your question: because of the way the program is funded and the bi-monthly visits from physicians, there is a lot more case conferencing and therefore there is a lot more in-depth conversation about how they are going to look after this client over the next period of time—which does not always exist anywhere else. It is only in pockets of how they will look after their palliative care clients.

Senator MOORE: Do you have any data or any paperwork on that? It is just that you draw particular attention to the fact that this is working. We would like to have something for the committee in terms of the background of the trial, how it is working—

Mrs Robinson : We could send that to you.

Senator MOORE: That would be really useful. That would be great. The other question, Professor Parker: you talked about the work you did in terms of specifically a research paper on using GPs with palliative care in aged-care facilities. Can we see that? Have you got some paper on that?

Prof. Parker : Yes, I have a final report that I can send to you. I did forget to add that, as part of that research program, we have developed a palliative approach toolkit, which is an educational toolkit which the Department of Health and Ageing has recently funded to provide 3,000 hard copies of that toolkit. Under the recent aged-care grants, Professor Liz Reymond, from Brisbane South Palliative Care, and I are doing a national rollout of that toolkit. That has happened subsequent to the inquiry.

Senator MOORE: I was hoping you would put that on the record. The toolkit was one of the things announced and it came specifically from your trial. But that was only one little bit of the trial.

Prof. Parker : That is right.

Senator MOORE: You alluded to the fact that there was much more in that trial. Did that work engage with the AMA in terms of the way that operated?

Prof. Parker : No; it was with the GPs predominantly. The rollout, which was with Liz Reymond, includes ANZSPM, which is the Australian and New Zealand Society of Palliative Medicine and the division of GPs—or whatever they call themselves these days.

Senator MOORE: I am constantly lost with—

Prof. Parker : It does include the GPs.

Senator MOORE: There are a lot of other questions that I would like to ask but the one I want to go to now relates to the Palliative Care Outcomes Collaboration, which is referred to on page 29 of your submission. I would like to know a bit more about that and the lack of data, which was mentioned in the last paragraph. How would an effective collaboration program work and what is its intent? The last paragraph also mentions the lack of data. This particular committee is phobic about data and the fact that there does not seem to been effective data collection. To get knowledge about palliative care in the nation you need to have that data, and your submission indicates that that is not happening. So I would like to give you a chance to put a little bit more on the record about the data stuff and the collaboration and how that should work.

Prof. Parker : With respect to the Palliative Care Outcomes Collaboration, you may want to seek some further information from Professor Patsy Yates or Professor Kathy Eager, who is involved in the national rollout of that. I guess from our point of view it is from being a user of that service. Blue Care is currently looking at incorporating the PCOC outcome measures for community. Those outcome measures are fairly high level and broad. They are really about phase of care and some symptoms that are assessed. It is designed to be a language, I guess, where you can talk to members of the multidisciplinary team to get a sense of where the client is up to in their phase of illness and what their symptoms are. But it does not seem to be able to provide really good data about place of care and anything where you want to benchmark your services, unless you have a certain number of services.

Mrs Robinson : For example, in North Queensland, for me to use PCOC as a tool in my palliative care and KPIs, I have to have nine domiciliary services scatters across North Queensland, collective as one, to be able to utilise it—to have the numbers that are needed to get the information from.

Senator MOORE: In places like North Queensland that would have a limited use because there would be such a variation between the nine services, you would think.

Mrs Robinson : Two of them are in major towns, like Mackay and Townsville.

Senator MOORE: That would be a link. In previous inquiries we have been given information about the Atherton Tableland, for instance, as a distinct area, which is quite different to Cairns. So there is that kind of variation.

Mrs Robinson : That is correct.

Prof. Parker : From a provider point of view, at the moment the data must be entered by the service, and it is not the same platform as our clinical service platform. So it is an extra burden, which is why you do not get 100 per cent buy-in from specialist palliative care services, particularly large service. For example, I am pretty sure that Liz Reymond in fact Brisbane South does not provide PCOC data. They have a very large service and there is the extra administrative burden to enter data on their own system and on another system which can be used for benchmarking nationally. I guess they use their own system in terms of looking at their own client outcomes now. So it is that duplication—

Senator MOORE: Which would affect the credibility of the whole process for the whole of Brisbane south, which is probably our biggest—and it is not there.

Prof. Parker : Yes, it is a big provider. But, in terms of residential, one of the frustrations for me—and I have been a researcher in this area for about 20 years—is that it is almost impossible to get good figures about how many people transfer from a residential aged-care facility into a hospital and actually die in the hospital; or do they come back? That data, I think, does exist—and I did many years ago have conversation with Diane Gibson from the Australian Institute of Health and Welfare—but we do not report it.

There is often a myth about the enormous volume of people being transferred from residential aged care into public hospitals to die, but we do not know the figures. We know how many people get transferred, but we do not know what happens to them once they are transferred—whether they come back. It is often appropriate to transfer somebody from residential care into a hospital—I am not saying that you should never do that—but until we really have a handle on the volume of that work and why those people are transferred and do not come back, it is hard to solve that problem.

Senator MOORE: It is often built up as a given that that happens, and people premise their statements on that. But we just do not know—

Prof. Parker : Yes. My experience, and I worked in South Australia for many years as well is in Queensland, is that there are very few people who do get transferred and that those who do are often in what we would call the old, low-care-only facilities where you do not have the 24-hour nursing. But, in the places that do ageing-in-place or that have the high-care staff, people generally do try to keep the residents in those facilities because that is their home and it is their wish to do that. The programs I have been trying to develop are to upskill those staff. I do not believe that everybody who is dying in residential aged care needs the care of a specialist palliative care service, but there are people with complex care needs who may need that service. They do need some support and mentoring to upskill and provide that care.

Senator FIERRAVANTI-WELLS: Professor, I might just pick up on the points that you made in relation to the ACVI funding and the specialist palliative care services in aged care. I preface my question this way: you are aware of what the Productivity Commission has said. Basically, it is recommendations to move to an entitlement based system. How would you see an entitlement-based system rolled out, in particular in relation to palliative care services? In other words, how would you see breaking down those services so that they are on an entitlement schedule—if I can put it that way—and then being available to aged-care facilities to directly provide those services in aged-care facilities, including services which may be currently provided by the state hospital system if they were able to be provided under, say, subacute or acute services with direct funding under an entitlement schedule?

Prof. Parker : If there was sufficient funding available, the larger providers such as Blue Care, Resthaven and a lot of the Catholic providers would have the capacity to be able employ specialist nurses to support people within residential care. That support can come either from the specialist palliative care service or, if the funding is with the aged-care provider, it could be provided there. It really is about having enough staff to be able to provide the care needs of a dying resident: time to be able to provide the level of hygiene needs; time with the family, in particular, during that time; time to have things such as case conferences; and time, when people enter residential aged-care and on an ongoing basis, to have discussions about advanced-care planning, which is very important and which will make sure that people's wishes are respected at the end of their life. That needs to be reviewed regularly. At the moment, often providers do not claim for the palliative care component of ACFI and there are two reasons for that. Firstly, it comes under the complex care needs area. Often if you have already reached your ceiling point under the ADL section then you do not need to add the ten points that you would get from palliative care because you will not get any more money. The number of claims that go in for palliative care probably do not reflect the number of palliative care clients that are in the system because from a paperwork perspective there is no added value to reclassifying people when they become palliative care patients. I am not sure if that will be changed; we have advocated for that.

Secondly, under the proviso currently in ACFI, to claim for that money you have to have a GP or specialist nurse sign off on a palliative care plan. That specialist nurse, at the moment, has to have five years experience in pain or palliative care management. It is quite rare to find those people to be able to do that in that setting. Or you have to have the GP. I have already demonstrated that getting a GP to come to a case conference—

Senator FIERRAVANTI-WELLS: It is hard to get to GPs to go to aged care facilities as it is, let alone in that setting.

Prof. Parker : It would be interesting to know how that funding would be administered and who is going to make those decisions. Is it based on needs or prognosis? Who signs off on that?

Senator FIERRAVANTI-WELLS: Presumably there would have to be some sort of assessment process that determines that Mrs Smith is in need of x number of services that may be available on the sort of schedule that the PC envisage and then presumably those services can be developed.

You made a point about the division of the state benefits. If you had more potential for aged care facilities to deliver palliative care services then it could be a simple funding transfer to deal with those issues. If we are able to shift the focus to residential aged care facility settings and those settings could deliver the services then we could do that by way of agreements between the states. Could you see that happening?

Prof. Parker : Yes. I am not clear on the announcement of that $20 million and whether that might be something that might work in that the money might go to the state services and be broken out. I know in Victoria under state funding they have now got eight positions in each of the consortiums in Victoria which are dedicated to support residential aged care facilities in delivering palliative care. But they are not adequate to cover what is required. The issue always is that specialist palliative care—as I am sure you know from this inquiry—is itself not funded adequately, so there is a tension between advocating for those services to provide care outside.

Senator FIERRAVANTI-WELLS: That is my point because at the moment it is there. This is where I think the Productivity Commission seems to set a framework for making comments about an entitlement system. Ultimately, palliative care services may well sit alongside respite or any other service and be a service that is available for persons who are assessed to be in need of that. The system for delivering those would then be presumably, as the PC outlined, some form of entitlement system, for example, a Medicare schedule or something like that which would then simply hold its own as another service that is available.

I want to focus on your comments about ACFI. Yes, we know how much angst that has caused. My concern, from your comments, is that the group that is particularly targeted falls squarely within the palliative care group. I have made comments about the ACFI funding potentially leading to queues and staff shortages because that is ultimately where it is going to hit. With these drastic changes at the top end, are we potentially going to see already difficult staff situations compounded? If you are going to have less money, you will potentially have fewer staff, and the hardest hit will be at that top end. That is how I read your comments, Professor; I just wanted to clarify that for the record.

Prof. Parker : Yes. Blue Care has looked at the impact of these changes, and about 200 full-time-equivalent staff positions will potentially be affected.

Senator FIERRAVANTI-WELLS: And that is just in Blue Care?

Prof. Parker : That is just in Blue Care.

Senator FIERRAVANTI-WELLS: So the changes that the government have recently announced will potentially translate to 200 full-time positions coming out of the system. If I understand correctly, they will come out at the top end and probably affect those in most need. Is that summation correct?

Prof. Parker : Yes. They will affect everybody, but of course now most people who enter residential care are at the top end of need. They are predominantly high-care clients.

Senator FIERRAVANTI-WELLS: Yes. I wonder if you could you have a look at the Productivity Commission recommendations, particularly where they pertain to palliative care, and provide us, on notice, your views as to the practical translation of those into changes. I have one last question to take on notice. How much more could residential aged-care facilities do, if there were a funding source under an entitlement schedule, to alleviate that burden that you were talking about of older Australians being forced to go into hospitals? How much of that could be better absorbed in our residential aged-care facilities?

Prof. Parker : It is difficult because we do not actually know how many—

Senator FIERRAVANTI-WELLS: Yes. In that, could you also point us to where you specifically see the data deficiencies and what you specifically think we should be asking the states for in terms of information pertaining to that. Thank you.

Senator BOYCE: When I became interested in the palliative care area about two or three years ago I was a bit surprised to find that Queensland could actually tell when people had three months left to live. Is Queensland unique in providing funding for the last three years of life?

Prof. Parker : Generally, most states across Australia have between a three- and six-month time frame in which funding may be allocated. Palliative Care Australia may be able to answer that for you. Specialist palliative care services across Australia generally do not have a set time frame for referrals, so they do not only take people for that period of time. Blue Care is a brokered service, so we get money from Queensland Health for a fixed period of time. That is the difference. The specialist palliative care—

Senator BOYCE: You are not the only service that that happens to in Queensland.

Prof. Parker : No.

Senator BOYCE: You have commented, as have many other people, that the situation for children and adolescents with palliative care needs is superior to that for adults. Would you like to comment on the systemic thinking or the values that cause that? What could we do to make the rest of the system as good as it is, from many submissions, for children?

Mrs Robinson : Mostly with the children, there seems to be a lot more money available, a lot more case conferencing with the families and a lot more linkage with the staff that will be looking after that particular person. It just seems to be a better service that is provided, from the front end all the way down the line, compared to what they have with older Australians that are in palliative care.

Senator BOYCE: Is there anything that has driven that—other than, perhaps, our natural reaction to poor sick children—in terms of better funding at that end? Do you think that is all it is?

Mrs Robinson : I think that is what it is, yes. I do not have the figures for that.

Prof. Parker : I think a lot of older Australians, particularly those in residential care, do not have a cancer diagnosis, so they are the non-malignant group of people. Specialist palliative care services have traditionally come from that cancer focus model. I think that translated, probably, quite well to children initially. Then there was the realisation that not all children die of cancer. I am not quite sure what the figures would be comparing children and adolescent deaths to older adult deaths, because children and adolescents is not my area. It may be partly a numbers game in terms of the volume of older people dying, the vast array of different conditions that that covers and the difficulty of getting a handle on that.

Senator MOORE: There was a figure of 30,000 earlier. There would not have been 30,000 children.

Prof. Parker : That is right. About one in four deaths in Australia occurs in residential aged care.

Senator BOYCE: You have spoken about the brokerage system that is used in Queensland out of hospitals for community type stuff as not being the way to go. Who should be the gatekeeper, so to speak, for community palliative care services? The GP, also, you are saying, is not the right place. You are saying we should be starting earlier. What should the system look like? Who should be the one who lets you into the palliative care system, so to speak?

Mrs Robinson : Obviously there would need to be an assessment phase, initially.

Senator BOYCE: Who would do that?

Mrs Robinson : Obviously the GP would have to do that, initially, because that is often where it starts. The hospitals might then get involved. They are all so different across Queensland in the way they treat their palliative clients. It ultimately then needs to end up with the provider who is actually going to provide the service. As it is now, there is a lot of gatekeeping that goes on in some of the rural and remote areas. A lot of the clients who are palliative in those areas receive no palliative funding from the hospital; the hospital keeps those funds. Then they will allocate—

Senator BOYCE: Sorry, I am not quite clear what you are telling me there.

Mrs Robinson : If you have a palliative client and they are in a rural and remote area, it is the hospital in that area that decides what community service is going to be brought in for that client to palliate at home. That can be quite inadequately funded by that particular hospital group if they do not see that as a palliative person. They may just keep them in the community without a lot of equipment, for example, and allocate very few hours to actually looking after the person at home and for the family to provide the care that is required to keep them there.

Senator BOYCE: I was a bit surprised by some of your comments about rural and regional people in terms of not being able to get access to oxygen at home or medications that they might have to wait a couple of days for. It is not like no-one knew these medications were probably going to be necessary, is it? So why weren't they ordered earlier? It just seems a strange system.

Mrs Robinson : Yes, but that is exactly what is happening out there, especially in Burdekin area.

Senator BOYCE: Why Burdekin?

Mrs Robinson : I am not sure.

Senator FIERRAVANTI-WELLS: Is that part of it, the community service obligations and the delivery of pharmaceuticals, Pfizer related?

Senator MOORE: No, I do not think so.

Senator BOYCE: No. That is why that did not make sense to me.

Senator MOORE: Talk to some of the specialists, and then you will find out.

Senator BOYCE: We will certainly have a look at that.

Mrs Robinson : It is such a different picture to what they do in Townsville.

Senator BOYCE: Professor Parker, you mentioned the Netherlands model of having a specialist palliative care position who presumably looks after a cluster of residential facilities. You said that that was more expensive. Are you aware of any work that would balance, 'Yes, that's more expensive but if it keeps people out of acute care it may well not be more expensive to the overall system'?

Prof. Parker : No. I do not think there is any evidence other than anecdotal evidence from the Netherlands. They have been doing it since 1990 and, clearly, you would think that they would not continue if it did not work. One nursing-home doctor usually does look after around 100 clients. Sometimes in the larger facilities you might have more than one doctor. But it is not just about keeping people out of hospital; it is also about quality of life and promoting residential aged-care facilities as homes where people can maintain quality of life and be well until they die—which is the palliative care philosophy. You need to have personnel who can not only do good assessments, order the right medications or stop the wrong medications, and look to the future to make sure the care people receive is the best that it can be but also support the family through that. So it is partly about stopping people inappropriately going to hospital. We also do not have any data comparing the outcomes for quality of life between that system and others. It is such a unique system that they do not tend to match it with that of other countries.

Senator BOYCE: Thank you.

Senator FIERRAVANTI-WELLS: Professor, in some of Blue Care's residential aged-care facilities that I have visited, you have certainly developed the one-doctor model, which I saw working very well at one of your major sites in Queensland. What you are suggesting is going to be a lot easier to do if you have a model where you have a doctor on retainer, if I can put it on that basis, which is the other way of potentially doing it—

Prof. Parker : Yes.

Senator FIERRAVANTI-WELLS: and then you can progress, if you have a doctor on retainer, like you have, who looks after all the patients. It is going to be easier to move on to the next stage, which is the palliative care stage—

Prof. Parker : That is right.

Senator FIERRAVANTI-WELLS: if you have that model in place. I just wanted to say that Blue Care in particular have developed this in some of their facilities—a system of doctors on retainer.

Prof. Parker : Yes. But there is a tension, because the rules are about client choice; the client is supposed to be able to choose their own doctor. At the moment, legislatively we cannot oppose somebody having a particular doctor. I have done research in organisations where I have had to write 40 letters to 40 GPs to tell them that we were doing some research in a particular facility and could they participate. If one or two registered nurses have to deal with 40 GPs, administratively that is a major challenge.

Senator SMITH: I have one question. Throughout the submission, you refer to the better utilisation of technology in a variety of different areas, including Indigenous health. Could you elaborate on that point for me? What types of technology do you mean? Is the problem that there is not enough support being given for the utilisation of the technology—in other words, the technology exists but the utilisation is poor?

Mrs Robinson : I think it is a bit of both. Quite a few of our staff need a lot more training to use that, along with the client base. But there is not the capacity out there to have that type of technology. A lot of centres do not have that sort of technology. At the moment, we are moving to trialling the NBN in clients' homes to see if we can improve care through that, but that is in its early days. That is where we are hoping to head.

Prof. Parker : It is the same in residential care, I think. The facilities just are not available. I know one suggestion was to look at videoconferencing for GPs in residential aged-care facilities, but we have difficulty just videoconferencing between Blue Care sites—let alone between a GP's office and a residential aged-care facility. And then how do you involve the residents who cannot communicate or who are too frail? It is possible, but at the moment I do not think the infrastructure is available. And, as you say, you also have to have the staff training and support needed to use that technology at both ends. It is a bit of a skill.

Senator BOYCE: I think it goes well with children and parents.

Prof. Parker : Yes. For a resident who cannot communicate, do you then have to have the family member there? The coordination of that would be an added burden on an already limited number of registered nurses in the aged-care setting.

CHAIR: We thank you very much. We have given you some homework. We would appreciate it if you could supply that within two weeks. Thank you very much of your time and your submission.