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Community Affairs References Committee
24/04/2012
Palliative care in Australia

BUTT, Mr David, Deputy Secretary, Department of Health and Ageing

CREELMAN, Ms Alice, Assistant Secretary, Cancer and Palliative Care Branch, Population Health Division, Department of Health and Ageing

DE BURGH, Mr Russell, Assistant Secretary, Office for an Ageing Australia, Ageing and Aged Care Division, Department of Health and Ageing

PARAS, Mr Andy, Director, Cancer and Palliative Care Branch, Population Health Division, Department of Health and Ageing

SMITH, Ms Ann, Assistant Secretary, National Partnership Agreement Branch, Acute Care Division, Department of Health and Ageing

SMITH, Ms Carolyn, First Assistant Secretary, Ageing and Aged Care Division, Department of Health and Ageing

[8:51]

CHAIR: I now welcome representatives of the Department of Health and Ageing. I know you all know the information about parliamentary privilege and the protection of witnesses and evidence. However, I remind witnesses that the Senate has resolved that an officer of a department of the Commonwealth or other state should not be asked to give opinions on matters of policy but shall be given a reasonable opportunity to refer questions asked of the officer to superior officers or to a minister. This resolution prohibits only questions asking for opinions on matters of policy and does not preclude questions asking for explanations of policies or factual questions about when and how policies were adopted.

We have your submission; it is No. 96. I invite you to make an opening statement and then we will ask you lots of questions.

Mr Butt : Senator, thanks very much. As you say, you have our submission, so we were not proposing to make an opening statement. I am very happy to answer questions.

CHAIR: Okay, thank you. Senator Moore, do you want to kick off?

Senator MOORE: We will probably go all over the place; that will be the easiest way. My first question is: with the various restructures of the department, why is it the Cancer and Palliative Care Branch? What was the rationale behind that title and when did that happen?

Ms Creelman : The establishment of the Cancer and Palliative Care Branch took effect from 1 July last year. There were a number of programs and initiatives within the department relating to cancer that had synergy in being brought together, and there was also synergy with the work of the palliative care section. Palliative care is, obviously, not only provided to people with cancer; a large number of people who receive palliative care do have cancer diagnoses. So there was synergy between the work of the various sections.

Senator MOORE: Was there any feedback to the department at the time from the various groups about the fact that, seemingly, this was exclusively linked with cancer? You would have read in some of the submissions we have had to this inquiry that, among the people who are interested enough to submit to the inquiry—and that is a select group that engage with us—there is a view that, when people think of palliative care as an issue, it is immediately linked with cancer, and that is seen as a limiting process. I am interested, from the department's point of view, whether there has been any feedback to that effect?

Mr Butt : I was not in the department at the time and Ms Creelman was not in the job.

Senator MOORE: I know that.

Mr Butt : If you look at the history of palliative care, you see it very much developed from the focus on cancer. But I think there has been substantial change over the past 20 years in relation to palliative care, recognising—and it is reflected in the national strategy—that palliative care is a much broader issue than cancer, even though, as Ms Creelman said, a lot of people who are in palliative care do have cancer. I think the change reflects the change in the way diseases have developed over time to a greater focus on chronic disease management. More and more around the world, as we are ageing and getting different diseases and dying of different things, specialised palliative care services have branched out more broadly to cover far more than cancer, taking into account cardiovascular disease, respiratory ailments, neurodegenerative diseases et cetera. So I think the broadening of palliative care services has been quite apparent in recent years and is continuing. Mr Paras, were you there at the time?

Senator MOORE: Can I get an idea, also, of the numbers in the cancer area in this branch and the palliative care area? You said 'synergies'. You can put that on notice. Also, the levels, what they do and whether there is any crossover of staff in the process. I did not want to interrupt, Mr Paras, I am sorry. You were going to say something?

Mr Paras : Yes, we did receive some feedback around concerns that perhaps the department was focusing palliative care predominantly on cancer. But the first assistant secretary from the department, Nathan Smyth, went to great lengths to assure everyone that that was not the case. Similar criticisms could have been focused prior to palliative care moving into population health division, when it sat with aged-care division. Similar criticisms were put forth then that perhaps palliative care was focusing only on aged care, when palliative care does not. Again, we go to quite great lengths to show that that is not the primary focus. Regardless of where we sit in the department, the focus for palliative care is all-encompassing.

Senator MOORE: We heard in previous evidence about a view that it is time to look at the guidelines again. That has been echoed in other submissions we have had. Your submission indicates that there was a significant review of the guidelines in 2005 which involved considerable consultation. Is there a time frame or a schedule within the department for how and when these things are reviewed and what stimulates it?

Mr Butt : There are actually two sets of guidelines. One relates to residential aged care and the other one to community care. The community care guidelines were released last year. Both sets of guidelines are NHMRC endorsed, so they go through quite a rigorous process in terms of levels of evidence and expertise. The residential aged-care guidelines are now due for review. I think Mr Paras could comment on where those are at.

Mr Paras : We are currently in the process of putting out a request for quotation to members of a panel that the department has to review and update the guidelines. That is currently in process.

Senator MOORE: That is for the NHMRC process?

Mr Butt : In accordance with the NHMRC process. So it will go through a similar process, expert panels, grading of evidence. We will be very happy to get feedback for that.

Senator MOORE: And public consultation and all that process. Can you remind me: how is that stimulated? It says that the last review of the residential one was in 2005. It is now 2012.

Mr Paras : There was actually an enhanced version in 2006.

Senator MOORE: It is a six-year timetable?

Mr Butt : It is a five-year time frame for all NHMRC guidelines. So it is due.

Senator MOORE: Overdue. That is fair, though, isn't it? It is overdue, if it is a five-year time frame, and it was in 2006. I am not trying to be difficult; I am trying to pin it down. If it was 2006 when it was endorsed in the last round and it is a five-year cycle, it should have kicked off last year.

Mr Butt : Yes.

Senator MOORE: That is just to see, and that would be the expectation. Now it is happening. It has gone out. There are people who are interested, and, as you would well know more than anyone else, there is a great amount of specialised interest in this area. So that at group would be aware that it is now going to happen and will have their chance to input.

Mr Butt : Yes.

Senator MOORE: And how long does it take?

Mr Paras : We are anticipating it will take about six months to conduct the work and then go through the NHMRC endorsement process after that.

Senator MOORE: Specifically from the last witnesses there was talk about community care and aged-care facilities. It seemed that the major issue was communication and availability of and access to services. You would have heard that and seen that in the evidence that we have received. I want to talk about the residential aged care. I know we are going to a review of the guidelines, and I know we had major announcements last week which will look at the whole area as well. It is specifically in terms of the palliative care aspects. You may or may not have heard the evidence from one of the people before about difficulties within an aged-care area as to trained personnel having awareness of the issues around palliative care particularly in the dementia space. We have had evidence that it is not only as to dementia but that it is particularly telling with dementia because of the inability to effectively communicate with people who are not able to communicate their own needs, particularly around pain and such things. It was about a lack of awareness and training of personnel. Secondly, it was about difficulties with communicating as a family member things like advanced care directives and the need to have changed treatments for people when you had an advanced care directive. The issue raised by the witness, and I am sure you will review that in the Hansard, was that there was a feeling that there was a lack of knowledge and moreso, perhaps for personal reasons or religious or spiritual reasons, a lack of wanting to comply with what was in an advanced care directive. So if there were an advanced care directive that said that there should be no intervention, that there should not be medical efforts made or that someone should be allowed to end their life in that way without intervention, there would be a reluctance and a sense that people would not respond to that need from the person or the family. Is your department aware of concerns of that nature? In terms of your understanding, how does that operate in an aged-care area? It is about, firstly, knowledge, training and awareness by staff of issues of dementia and palliative care and, secondly, how advanced care directives are known, understood and implemented in aged-care facilities for which your department is responsible.

Ms C Smith : The department is certainly aware of the issues that were raised by Alzheimer's Australia. Those same issues were raised by people with dementia and by other people accessing aged-care services as part of the recent consultation processes that have been undertaken as part of responding to the Productivity Commission report. So I think the issues are well understood. I think there is a range of things that are currently in place to support training of aged-care workers and also accreditation standards which require these issues to be addressed. But I think the government has acknowledged that this is an area requiring further action. You would know that under the aged-care reform package announced last Friday there is a significant priority attached to improving the palliative care training support that is available to residential care services. In terms of things that are currently happening, we have the accreditation standards which specifically have an accreditation outcome relating to palliative care. So that is an existing requirement. Also, we already conduct a significant amount of training in the aged-care area, and I can get Mr de Burgh to talk about some of that in more detail if you want.

Senator MOORE: Can we get that on notice?

Ms C Smith : Yes.

Senator MOORE: You have attached some information to your submission but not specifically on the training thing. If we get that then we can ask more questions if required. I am interested in the advanced care directives and awareness by the department about how they operate and perhaps about the variation in understanding throughout the industry about what is their role, how they operate and what is the responsibility of staff members when an advanced care directive is in place.

Ms C Smith : One of the complexities, as I think you acknowledged in your earlier questioning, is that we have a framework that varies around Australia so there is not actually a national framework.

Senator MOORE: It is a bugger that Constitution!

Ms C Smith : Certainly aged-care providers, as part of their obligations under the accreditation standards, would need to have an understanding and an appreciation of that area and of how to respect the wishes of their residents. But, as you have acknowledged, it is a complex area, one where sometimes personal values can intrude. I think that is probably a factor in the hospital setting as well as in the residential care setting.

Senator MOORE: Does the department have records of issues around this, through people writing to the department, through the various consultation mechanisms you have, or in the accreditation process where the people doing the accreditation go into the various facilities and talk with people? Is the application or knowledge of advanced care directives an issue that comes up in any of those fora?

Ms C Smith : It certainly was an issue that was raised directly with the minister as part of his recent conversations on ageing. There was quite a powerful story that he heard from one of the events in Darwin—I think that was where it was—where a woman told of how she had 'DNR'—

Senator MOORE: That's right.

Ms C Smith : tattooed on her chest. But she also had tattooed on her back 'PTO' in case she fell—

Senator FIERRAVANTI-WELLS: It was reported. I did see a news—

Senator MOORE: It has been quoted much.

Ms C Smith : So, yes, individuals have raised with him directly, in quite a powerful way, the importance of having their wishes respected and the importance of dying with dignity when they are receiving either residential or community care. It is an issue of great significance for the population of older Australians needing to receive care.

CHAIR: I have a question going back to the recommendation that we have a standard approach: an agreement presumably—dare I say it?—using the COAG process, across Australia. Is this under active consideration?

Mr Butt : Sorry, Senator, are you referring to—

CHAIR: I am referring to a standardised approach across Australia to advance care directives. The suggestion in many of the submissions is that we have a standardised approach.

Senator MOORE: How does that fit between you and Attorney-General's?

Mr Butt : In fact, it was considered by the Australian health ministers and a national framework was endorsed by health ministers late last year and so has been released. That sets out a range of principles that should be followed. Legislation is very much a state and territory issue so this was about trying to get standardisation across the country. I notice today that South Australian health minister John Hill has announced that they are reviewing their legislation to simplify it, which I understand is in accordance with what the framework suggests.

CHAIR: That is done against the principles of the framework?

Mr Butt : That is my understanding.

Ms Creelman : My understanding also is that that national framework was referred to the Standing Committee of Attorneys-General, as well, for consideration. In addition, the government funds the Respecting Patient Choices project, which aims to set a sort of quality assured standard for advanced care planning nationally. Currently it is trialling approaches to advanced care planning for people with dementia and other special needs groups. That is not a legislative approach but it is a standard-setting approach. The cross-jurisdictional Palliative Care Working Group has advanced care planning as one of the issues that they are trying to progress.

Mr Butt : Minister Hill also said in his announcement that once the legislation is through they will embarking on a publicity campaign with GPs, senior citizens groups and residential aged-care facilities to get them to understand the new arrangements and how they will apply in those services.

Senator MOORE: It is probably my ignorance but I had great trouble understanding how the PCOC worked, and the tables that were in this submission. I read them a number of times. It is allegedly telling me that things are getting better. That is what the text said. I do not know how the charts are telling me things are getting better.

CHAIR: Yes. It was like double-dutch to me.

Senator MOORE: I just need to have some advanced help somewhere to read the table. That would be helpful.

Senator FIERRAVANTI-WELLS: That is a nice way of putting it.

Senator MOORE: The text around it said that this was a tool that would give some benchmarks for how palliative care was operating across the country, which is one of the things people are asking for. I was really excited by that. And then I got to the table and I just could not understand it. Is this something that people in the industry do understand, and do they agree that things are getting better?

Mr Paras : PCOC is basically a benchmarking project that has been funded by the department for a number of years.

Senator MOORE: Since 2006, is that right?

Mr Paras : Yes. PCOC goes into services and helps them benchmark and improve their performance against four markers.

Senator MOORE: And then we had more figures from PCOC in appendix 4. Can you assure me—and I will talk to someone later rather than taking up this valuable time—that this data will prove that there is a lessening of the time between people seeking help and getting it?

Mr Paras : One of the key aims of this project is looking to improve waiting times. Whether that translates into individual services is a matter for those services.

Senator MOORE: Right. And it is indicated by individuals and services. I will talk to the department on that.

Mr Paras : In the main, they are improving services.

Senator FIERRAVANTI-WELLS: In your submission you talk about palliative care provision. Could you outline for me the way in which palliative care is funded? You said in your opening statement that you do not directly fund specialist palliative care provisions but you do provide support in two ways. Can you give me an overview, and then I might take you to more specific questions.

Ms Creelman : The overview is that the government provides financial assistance to state and territory governments to actually deliver and operate palliative care services.

Senator FIERRAVANTI-WELLS: As part of health agreements?

Ms Creelman : Yes, and as part of—

Senator FIERRAVANTI-WELLS: The subcomponents of it.

Ms Creelman : subacute care. Ms Ann Smith can give more details. The other element is the National Palliative Care Program, an Australian government initiative which aims to improve the quality of, and access to, palliative care. Some of the projects we have been talking about—the training projects, the guidelines, PCOC—are part of the National Palliative Care Program. But funding for palliative care service delivery is the funding that goes to states and territories. Ms Ann Smith could give more detail on that.

Senator FIERRAVANTI-WELLS: Yes, Ms Smith, if you do not mind. I will then go to the comments that were made by the Productivity Commission about palliative care. If we have got the states and territories delivering palliative care and a greater need in the federal residential aged-care sector, I would like to now understand what your thinking is in terms of marrying these things together.

Ms A Smith : I will do my best. There are probably two parts to talking about the funding that relates to palliative care. One is under the national partnership agreements. There are two national partnership agreements that have specifically provided funding for subacute care, which includes palliative care: the National Hospital and Health Workforce Reform and the National Partnership Agreement on Improving Public Hospital Services.

Senator FIERRAVANTI-WELLS: Is that where the famous 1,365 beds come into it?

Ms A Smith : That is correct—1,316 beds. That is the Improving Public Hospital Services NPA. That is $1.6 billion over four years, or 1,316 beds, for subacute care. As you may recall, subacute care includes palliative care, rehabilitation, geriatric evaluation and management and psychogeriatric care—and in this NPA it also included subacute mental health.

Senator FIERRAVANTI-WELLS: But we are not yet anywhere near identifying where those beds are going to be?

Ms A Smith : Yes, we are.

Senator FIERRAVANTI-WELLS: How many are in palliative?

Ms A Smith : I will just talk about a bit of background first if I could.

Senator FIERRAVANTI-WELLS: Before I drill down to the details.

Ms A Smith : Just to be clear, under the national partnership agreement the Commonwealth provides the funding for the 1,316 beds. The states and territories decide on what they are going to spend and where they are going to spend it. The Commonwealth has no direct control in determining that palliative care beds should go to Queensland or that rehabilitation beds should go to Victoria. The states and territories provide that. What they then do is provide the Commonwealth with an implementation plan about how they plan to spend the money, obviously for all of the NPA funding but this area particularly. Then they provide us with progress reports on a six-monthly basis.

I have information here from the progress reports that we finalised from the first half of last year. I have the information for the second half of last year, July to December; it is just in the process of being finalised with the minister. The numbers I will give you now are, in fact, relatively old numbers and they have improved since then. The other thing to note about this is that the states and territories have been a bit slower in getting to the target in those numbers because, under this particular NPA, the Commonwealth and all the states and territories had to agree to a nationally consistent methodology for measuring growth. That took, as you might imagine, a little bit of time to get finalised. Because of that there was some delay in payment of the funding under schedule E of this NPA.

Senator FIERRAVANTI-WELLS: As opposed to the definition of what is a bed.

Ms A Smith : We did not discuss that at all I can assure you! The other thing about this part of the NPA is that it funds beds or bed equivalents. One project is funding online services so that people in remote areas can access the palliative care specialist or a rehabilitation specialist online. Other places are purchasing equipment to support people in the community. That is why we needed a methodology as to how that translates to a bed or a bed equivalent. That is work that had to be done because it had not been done in that particular way before. These figures are beds and bed equivalents.

From the progress reports that were finalised for the period 1 January to 30 June 2011 for palliative care there were 104 beds identified which were made up of 99 beds and 5.6 bed equivalents. They were operational beds for that period. I do expect all the states and territories to meet the targets for the beds and bed equivalents over time. We will also be publishing the implementation plans certainly prior to the end of this financial year—pretty well as soon as we can once we have finalised a few things with the states and territories. That is one part of the funding and the previous NPA on Hospital and Health Workforce Reform provided $500 million to states and territories. Its measurement was improvement in services. States and territories had to commit to improve the number of services by five per cent each year, so it was a different sort of measure. The results of that to date are that over half of all states and territories have met the 20 per cent which was the total, or already gone beyond that amount and they have all met the five per cent over each of the years that they have been required to.

Senator FIERRAVANTI-WELLS: When you take those two together, bearing in mind that $1.6 billion is for a range of different things, how much of that is the palliative care component? In relation to the National Palliative Care Program we are talking $180 million. I just want to get a handle on the amount of Commonwealth money that is actually in palliative care.

Ms A Smith : For the old NPA, the five per cent increase, I cannot provide that detail now. I am not sure that I have it in that specificity about which service it provides but I will have a look at that and see whether I can provide it on notice. In terms of the NPA on improving public hospital services they have given me a lovely table but they have not totalled it up for me—yes, they have. At this point allocated funding for palliative care for that period was $49 million.

Senator FIERRAVANTI-WELLS: To round it off, we are talking $180 million, $49 million—

Mr Butt : It is actually very difficult to say how much we are spending on palliative care.

Senator FIERRAVANTI-WELLS: I am just trying to get a handle on it. I appreciate that that is just two components of it. I want to get a handle on how much money is being spent and where the palliative care buckets of money are. That is what I wanted to explore.

Senator MOORE: If we could see how much we can get of the table Ms Smith has in front of her, that would be very useful.

Senator FIERRAVANTI-WELLS: I think Mr Butt was saying that there are other parts of DoHA that are rabbit warrens with money.

Senator MOORE: I would like to find other rabbit warrens, but I would very much like to see the kinds of data that Ms Smith has. We would like as much as you have. You have the table across the states and the beds and the allocations. How much and what of that can we have?

Ms A Smith : Yes, I will certainly do that.

Senator MOORE: That would be useful.

Ms A Smith : That will probably need timing with the publication.

Senator MOORE: That would be good. We do not have anything of that nature.

CHAIR: The issue is, obviously, augmenting that with the announcement that was made on Friday.

Mr Butt : There are a whole range of buckets in the sense that what Ms Smith is talking about relates particularly to subacute care but of course it does not include the acute-care funding that we provide.

CHAIR: That is what we are trying to get a handle on.

Mr Butt : It is extremely difficult because we give that acute-care funding to the states. In the arrangements that have been put in place, which Ms Smith might want to talk about, in relation to activity based funding there will be subacute and non-acute funding formula in terms of activity based funding applying from 2013-14. That may give us a greater handle on palliative care, but I am not quite sure where we are at on that.

Senator MOORE: I want to follow up on that, Mr Butt. I am looking at page 6 of your submission which is looking at the way the two particular programs operate. You talk about the NPA HHWR. It says that this is the program that came out and gave the amount that went to the states of what they could spend. It says that at this stage there is still variation in the way the states report back. I am interested as I thought that plan started in 2009. Is that right?

Ms A Smith : Yes, that is correct, Senator.

Senator MOORE: I know it is difficult to get people to agree to stuff, but the money went out in 2009 and that was really an extension of previous money, the plan around money going out in the subacute area since about 2000. This was the 2009 spending going out. We still do not have agreed standard reporting that can give us a picture under that bucket of what they are spending and where. Is that right?

Ms A Smith : Yes, that is true.

Senator MOORE: Do you know how far along the negotiation stage it is?

Ms A Smith : Yes, I do.

Senator MOORE: What is today's story about where it is?

Ms A Smith : We had a meeting just last week.

Senator MOORE: What was last week's discussion?

Ms A Smith : It has been an ongoing concern for the Commonwealth. Most states report in a similar manner, but not all states do. They all come out of very different reporting systems. We looked at subacute care as a total. Rehabilitation is the most advanced in reporting because they simply seem to have had more systems in place for a longer period of time. All of the other areas of subacute are still under some level of development and the states and territories have taken individual approaches to that. Under this particular NPA, the Hospital and Health Workforce Reform NPA, there is a requirement to come to consistency. As I say, we have been working with the jurisdictions on trying to finetune that and we have reached progression. In fact in the end this information should be published. It goes through to the COAG reform committee and through that process it gets published. We are hoping that we will have something through to CRC in the next couple of months that has a fairly consistent approach. They cannot have it completely consistent. There will be information about how it differs. One state might differ from the others in various ways. Where the final answer, I think, will go for measurement and counting, whether it be for dollars and beds and services as Mr Butt mentioned, was under the activity based funding. With the National Health Reform Agreement the establishment of the Independent Hospital Pricing Authority has the jurisdiction to progress the ABF funding. In relation to subacute care in total there is a delay period for activity based funding to commence for that. The IHPA, the Independent Health Pricing Authority, has a process in place now with all jurisdictions. It also has called for public submissions to see how activity-based funding is best structured to meet the needs in subacute care, because, while I would hesitate to say that acute care is simple, it is much simpler than subacute care because of the venues where subacute care can be provided and what is covered under the National Health Reform Agreement. So that is the process now, and I think that is the long-term real answer to the consistent measurement. The NPAs were a product of their time, as was already mentioned. The first one had a measurement of percentage increase of services and the second one is the number of beds that it has increased by, so comparing between the two does not help either.

Senator FIERRAVANTI-WELLS: Wasn't there a 1 July time line on the issues with activity-based funding?

Ms A Smith : Not for subacute. Subacute has until 2013-14 before it commences. I am not certain of this, because I am not involved directly in that side of things, but I am given to understand that a number of states and territories are going to do some mirror funding, if you like, over this coming year for subacute so they can see what would have happened if they were funded under an ABF model and so that that can inform the discussions they are having about how the funding is in fact structured.

Senator FIERRAVANTI-WELLS: Now we come to Mr Butt's point about the other buckets.

Mr Butt : They are not so much buckets, but other programs, of course, with—

Senator FIERRAVANTI-WELLS: Sorry, I did not mean to be flippant.

Mr Butt : But of course we make payments under the Medicare Benefits Schedule, and there are some specific items there in relation to palliative care, for specialist palliative care services. Apparently the MBS provides rebates for palliative care specialists under group A24, 'pain and palliative medicine'.

Senator FIERRAVANTI-WELLS: You did make reference to that in other parts in there, I think.

Mr Butt : Yes. The total palliative care service is paid out—

Senator FIERRAVANTI-WELLS: Here we go. Is this covered under the range of palliative care arrangements, Mr Butt? You start at page 11 of your submission and you then talk about the primary health component, the Medicare Benefits Schedule, the Pharmacy Practice Incentive Program and the Pharmaceutical Benefits Scheme. Those are the areas.

Mr Butt : That is right.

Senator FIERRAVANTI-WELLS: And each of those has a component.

Mr Butt : Yes. The other point, just for some clarification on your point about the expenditure of $180 million on the National Palliative Care Program, is that that was actually over a 10-year period. The annual expenditure last year was $23 million.

Ms Creelman : Yes, 2010-11.

Mr Butt : When we have gone to our flexible funds and the reduction in the number of programs in the department from 159 down to 18, it has now gone into the chronic disease and—

Ms Creelman : The Chronic Disease Prevention and Service Improvement Fund.

Mr Butt : That is it, yes.

CHAIR: While we are on funding, I have noticed in SARRAH's submission that they make a point about finding it difficult to find out how much money is allocated to regional and remote Australian communities. Is it possible to get a handle on that? I am sure you have read the submissions. You know that a number of submissions raise the issue of access in regional, rural and remote areas and how we can get a handle on how funds are spent there.

Ms A Smith : For the National Partnership Agreement on Improving Public Hospital Services and the beds and bed equivalents, we certainly can provide what the states and territories have committed to in rural and regional areas.

CHAIR: Yes. Is it possible to get it under the other—we are not calling them buckets—areas of funding?

Ms Creelman : We can give you information under the National Palliative Care Program on specific projects that have targeted rural activities. In terms of the other types of funding like MBS and PBS, I think that would be extremely difficult.

Mr Butt : On acute care, no, we would not be able to do that.

CHAIR: Okay. If you could do your best to give us what you can, that would be appreciated.

Ms Creelman : I will.

Senator FIERRAVANTI-WELLS: The second part of my question was about the interface at residential aged care, and I then take you to page 11 of the submission. The Productivity Commission made its comments in relation to, obviously, palliative care as a core issue, and in your submission you have identified the 340,000 older people per year who were unnecessarily admitted or readmitted to the acute hospital system. Has the department, as part of the work associated with its response to the Productivity Commission, looked at the costs associated with that and how that could be more cost-effectively delivered in a residential aged-care setting?

Ms C Smith : I think, if you look at the measures announced on Friday, you will see that there was quite an emphasis on the important connection between the aged-care and health systems, and there were a number of different components to that. There was an important initiative around better palliative care and support in aged-care services; that is recognising that aged-care providers are increasingly looking after residents with quite complex palliative care needs.

Senator FIERRAVANTI-WELLS: That is the $21.7 million?

Ms C Smith : That is the $21.7 million.

Senator FIERRAVANTI-WELLS: Is that new money, Ms Smith, or is it just a reorganising of other funds?

Ms C Smith : If you go to the document Living longer, living better, the table at the back sets out all the spending measures. It talks about what the savings and the redirections are and then gives a net cost down the bottom.

Senator FIERRAVANTI-WELLS: Since it is just me working it out, you might like to give me some assistance there! As Senator Moore said—how should I put this?—coming to terms with a lot of this since Friday has been somewhat of a challenge, Ms Smith.

Ms C Smith : I think your office has requested a briefing from the department—

Senator FIERRAVANTI-WELLS: Yes.

Ms C Smith : and I think it is probably best if we go into the depths of the aged-care reform package in that setting.

Senator FIERRAVANTI-WELLS: Yes. I think a briefing would be good.

CHAIR: It is likely that all of us will want such information, and you can guarantee there will subsequently be questions coming back from the committee—

Senator FIERRAVANTI-WELLS: I think that probably would be useful. We have time, Chair, in relation to this inquiry, and I suspect that after my briefing—and I am sure Senator Moore—

Senator MOORE: Absolutely. I am the same.

Senator FIERRAVANTI-WELLS: Are you getting a briefing as well?

Senator MOORE: I will be requesting one.

Senator FIERRAVANTI-WELLS: So, Ms Smith, if that is okay, it is probably better if we do it that way—that we come back to you in relation to that.

Ms C Smith : So that is one initiative that is very relevant here. The other initiative is about promoting better practice and partnerships. We are trying to introduce initiatives to encourage providers to work with health insurers and other health services to deliver short-term or intensive healthcare services in a residential setting. I think that is going to be quite an exciting initiative—to break down some of the regulatory and funding barriers that have been there in the past that perhaps prevent an aged-care provider having a palliative care type bed service with more intensive support than they would normally be able to get.

Senator FIERRAVANTI-WELLS: In other words, you are envisaging that aged-care facilities could have extra beds that they could use for palliative care.

Ms C Smith : There are some providers who are already trying to work in that area, and I think you would probably be aware of some of those—

Senator FIERRAVANTI-WELLS: Yes, I am aware of those; I have come across some of them.

Ms C Smith : So this is funding to be able to explore how we could encourage those sorts of models. There are barriers within the current aged-care funding arrangements that do not facilitate that as much as you would think is desirable, so this gives us an opportunity to explore with the sector—

Senator FIERRAVANTI-WELLS: And is that the $25 million you are talking about? Sorry; I am looking at the fact sheet Better health care connections. So there is the additional money for palliative care, which is $21.7 million over five years?

Ms C Smith : Yes, that is correct.

Senator FIERRAVANTI-WELLS: And then, in that fact sheet, you also talk about the $25 million to support initiatives to encourage providers to work with public and private healthcare providers. We are talking specifically about palliative care, but I would envisage that you are looking not just at palliative—

Ms C Smith : Psychogeriatric is the other area that has been raised with us. Palliative and psychogeriatric are the two areas of care, I think, where providers would really like the opportunity to get more intensive health support than they have previously been able to. We have an existing program, Encouraging Best Practice in Residential Aged Care, where we have looked at implementing best practice in aged care.

Senator FIERRAVANTI-WELLS: Yes, I am actually aware of that program because I recently went to a facility where they were doing some very good work in relation to pain management with some Japanese methods.

Ms C Smith : We have funded a range of projects. Pain management is one of the areas we have focused on and it is obviously really relevant in palliative care. We have also funded some particular palliative-care projects and have got funding of $19.4 million in the aged-care reform package to do some further work in that area.

CHAIR: How soon will those programs start? Next financial year? Sorry, I do not have that particular information.

Ms C Smith : That is a 2012-13 initiative.

CHAIR: Secondly, a number of submissions have raised the issue that ACFI does not adequately accommodate palliative care. The ANF and the palliative nurses submissions also raise an issue around residential facilities no longer having enough nurses for palliative care. Are all those things on the table in terms of that funded work?

Ms C Smith : We also have obviously as part of the aged-care reform package specific measures around workforce, which will include consideration of training and the amount of support available to the workforce in aged care. If we are going to have a separate session, I suppose—

Senator FIERRAVANTI-WELLS: But that is partly associated with that compact. You will be starting the preliminary stuff in relation to that in September, but that is not going to kick in for a while, is it?

Ms C Smith : As you would appreciate, the aged-care reform package covers a very complex range of issues. There are different implementation pathways for different parts of the package. We are happy to go through in some detail in separate briefings.

Senator FIERRAVANTI-WELLS: I think it is going to be really necessary, Senator Siewert, to see where the money is being moved from. As part of that process, Ms Smith, it would be really helpful for us to know in our respective briefings—you have moved money obviously to things that may have been working or may work better in other ways—where you have moved money to do a better job, why the previous program was not working. Without looking at blame or anything like that, but because we all take a keen interest in these ageing matters, we would like to understand why you have moved money and why you think that its being redirected in a particular way is actually going to achieve things in a better way.

CHAIR: I think that is right. We had already flagged that we would be asking you for this particular inquiry. I think we should get the briefings and put some questions on notice, so we have that background information, and then at the end of this inquiry ask you back.

A number of submissions raised HACC. I think from some of the submissions that there is a misunderstanding around about when HACC can and cannot be accessed. One submission says you cannot access HACC below 65 palliative care or to support care in the home for palliative care. Is that correct?

Ms C Smith : I do not believe that is correct—I will go back and check for you. Obviously, we have the current Home and Community Care program which has been a joint program which cares for people under 65 and to people over 65, but that is available to younger people who need support. Home and Community Care, though, is basic level support. It is not necessarily going to be the best option for people at the end of life, but I do believe it is available and will check it for you.

CHAIR: That is what I understood. I suspect there is some misunderstanding because of the differentiation between what the state pays for in terms of disability and what the Commonwealth pays for. I would suggest that if one group or one person is misunderstanding it there may be others. Secondly, the way I read some of these submissions is that they see HACC sometimes as being the only service that people in the community can access. I wonder if it is in fact the case that people are accessing HACC in an attempt to fill out community care because they cannot access community care for home care or palliative care at home any other way. Do you know if that is the case?

Ms C Smith : That has not been specifically raised with me, but certainly HACC is seen as a very valuable part of the support available to people who need it in their home. I certainly could not rule it out, but it has not been raised with me specifically.

CHAIR: There are a number of submissions that raise it. Could I ask you to have a look at those submissions and give us your comments on notice because I think they raise some quite significant issues. We are talking about organisations that work in this space.

Senator MOORE: And there are significant variations amongst those. Some of these submissions clearly identify which date they are from as well.

CHAIR: If you could look at that, that would be very much appreciated.

Ms C Smith : Yes, I will.

Senator FIERRAVANTI-WELLS: In looking at the palliative care needs of the population I just specifically wanted to focus on CALD. For obvious reasons, it is an area that I take a particular interest in. You mention in your submission attitudes and approaches. In terms of the sort of discussion we were having earlier about new and innovative ways, are we going to put some innovative thinking into areas such as rural, remote and the Torres Strait, particularly in the palliative care space where there are cultural imperatives and different attitudes? Are we going to start seeing some creative thinking there?

Ms C Smith : Very much so. If you look at the package you will see it has a strong emphasis on recognising that people come from very diverse backgrounds, and we need to provide more support to aged-care providers to enable them to cater to everyone regardless of their background. There were particular groups highlighted as part of that.

Senator FIERRAVANTI-WELLS: The particular reason I ask is that obviously not all people in our post-war migration had a very high levels of schooling or understanding, so when they lose the working English that they may have had in many cases they do not just revert to, say, Italian but to a dialect of the Italian language. I was recently in Perth. I think I shared this with Senator Siewert. There was a fellow there who the aged-care facility had waited a month to find someone who spoke this old gent's language. He was about 92 or 93. It had taken them a month to find somebody who spoke his particular dialect. These are challenging issues because interpreter services are not going to deal with that because most of our interpreters will be fluent in Italian, Mandarin or Cantonese. They will not have fluency in dialects, which I think is going to cause us some real issues. I just wanted to put that on the table.

Ms C Smith : As part of last year's budget we put some additional support into translation services.

Senator FIERRAVANTI-WELLS: The $5 million?

Ms C Smith : Yes. But we acknowledge in this package that we need to do more to support the very diverse demographic that will be coming forward.

Senator FIERRAVANTI-WELLS: As part of that, is there some intention to work more broadly with organisations that are in that space to look at new and innovative ways that we might be able to address some of these issues? Is that envisaged as part of that interface?

Ms C Smith : We will be providing funding through the Aged Care Service Improvement and Healthy Ageing Grants Fund to enhance the capacity of aged-care services to provide care to people from diverse backgrounds. We would be hoping to work as widely as we can to capture the range of diversity that we need to.

Senator MOORE: We will have more questions when you come back to see us, but a lot of the questions in this period have been around ageing and dementia because we have had a lot of input on that. But, as you well know, the services are much wider than that. I am particularly interested in Aboriginal and Islander issues. We have had a number of submissions looking at return to country in particular and the costs of that, which can become extraordinarily high. I know there are great difficulties there concerning which bucket that comes out of—it can become a very big bucket. The other issue is youth and families with many conditions including cancer but not specifically cancer. You know we have received a submission from the Cancer Council that looks at the issues in their area, but there are also families who have genetic conditions, which can devastate the families, particularly from a very young age.

In the submission, there is nothing much about the different programs. I know a lot of the delivery is at the state level, but I could not get anything from your submission at this stage because of the focus on the aged-care aspects of those other areas. If I could get some information from you later about that, it would be very useful. It could well just be that you give the money to the states and it is up to them what they do, but I would not mind having that clarified.

Ms Creelman : To clarify, it is about the delivery of services to youth and families?

Senator MOORE: Yes. We have concentrated in our questions, and it is the same even in the submissions, on the ageing population, aged care and those links. I am referring to the other groups, particularly families, that need access to services in this area. It varies so greatly and the demands vary so greatly.

Ms Creelman : And the question about return to country?

Senator MOORE: Return to country and Aboriginal people. One of the submissions has a poignant story, a case study, which had a really good result because it worked, but for that one story there are many that are not working. It is a question of how you handle that. This story looked at the women of the NPY, which is an awesome organisation, but not everybody has access to it. How does that operate? Is that covered under the Australian government's Closing the Gap scheme? Are the services specifically for Aboriginal-Islander people under palliative care also part of what we count as health funding under Closing the Gap? I have never seen it specifically mentioned, but I would like to know how it fits.

CHAIR: Is not just about return to country; some people do not want to leave country in the first place. There are a range of services.

Senator MOORE: Families are involved—there are so many issues there. We need to be aware, but I think we are becoming more aware.

CHAIR: Thank you very much for your time. We have already given you a whole lot of homework and there will be more.