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

McMASTER, Dr Yvonne Helen, Private capacity

[16:24]

CHAIR: I welcome Dr Yvonne McMaster. You have been very patiently listening all day. Welcome. I know you know the pack drill. I understand that you have been given information on parliamentary privilege and the protection of witnesses and evidence.

Dr McMaster : Yes, thank you.

CHAIR: Do you have any comments on the capacity in which you appear?

Dr McMaster : I am a retired palliative care doctor and I am an advocate for palliative care now.

CHAIR: Thank you. We have your submission, No. 92. I have certainly read it. I invite you to make an opening statement and then we will ask you some questions.

Dr McMaster : I am looking forward to discussing it all with you. I would like to give you an outline of what is needed to help people face the end of their life, and their death. I speak from 40 years experience of helping dying people and their families. I was actually at the very beginning of palliative care in Australia when, in 1974, I was invited to become a VMO at a hospice in my area. I was hooked straightaway and have been ever since. Since I retired, after 22 years as a palliative care specialist, I have led a group of patients with whom I meet weekly who have advanced cancer. It has given me an intimate knowledge of the needs and the current gaps. Every individual, of course, has different needs, but the bottom line is first-class symptom control, with its impeccable attention to detail, careful assessment and meticulous follow-up. This is real, difficult, fascinating, satisfying medicine.

But physical symptoms are not the only problem. How do you help people deal with all the practical, emotional and spiritual problems they face at the end of life? What can help when the going gets tough is regular contact with highly competent, reliable clinicians who can guide the patient on a well-trodden path—well trodden for the clinicians but new and scary for the patient. We walk the path with the person and their family, and it helps. As ANZSPM, the Australian and New Zealand Society of Palliative Medicine, say in their excellent submission to you, they 'listen to the spirit of the patient' and attend to 'the multiple fears, concerns and regrets that proximity to mortality entails'. Some doctors or nurses are able to do this on their own; many need the help of a multidisciplinary team. Palliative specialists also have a role in encouraging wise decision-making regarding appropriate practice goals: whether to persist in trying to prolong life in the face of serious side-effects of treatment or to focus mainly or wholly on improving quality.

One problem is that up to now we have expected GPs to do quite a lot of palliative care. But general practice has changed. Gone are the days when all GPs did home visits and after-hours consultations. Think of the World Health Organisation definition and think whether a busy GP can really do it. Where is the multidisciplinary team? Where is the time for psychosocial and spiritual support? There are still some wonderful GPs around, but the times are against them. I believe that we must expect that palliative care teams will do the majority of the work—and there is a great deal for them to do.

What is needed? We need more money and we need many, many more workers. More and fairer funding will reverse the demoralisation of the palliative care workforce over recent years. A depressed and demoralised workforce cannot attract others to join them. The Commonwealth have to make sure that the money they give actually gets to where it is intended. And the funding has to be recurrent. If the funding stops, the services stop and the very good expertise and staff go elsewhere. The stories about money diverted to prop up overspent local health budgets are legion. We need better regulation of area health services, who must have palliative care as a higher priority than it is at the moment. Palliative care funding seems to be the last thing on their agendas. I would like to see KPIs for the area health services regarding whether they have adequate staff in their palliative care services or how many emergency admissions occurred to acute hospitals in the last weeks of life because there were not adequate community services.

We also desperately need charismatic palliative care specialists of the highest calibre in the teaching hospitals, where the medical students are. That is what catches the attention of the students and attracts them to the specialty. Universities must teach palliative medicine, and the teachers must be able to inspire young people to go into a specialty where they can really make a difference to people's lives and wellbeing. The ANZSPM submission recommends that the Commonwealth government provides funding for accredited positions for training in palliative medicine, and I would like to add, 'and lots of them'.

Shared carer arrangements such as those in Victoria described by the Motor Neurone Disease Association are fantastic and efficient. I commend their submission to you too. The need for better funding is across the board. The metropolitan palliative care services need more hours to consult and teach throughout rural and regional areas, and they have to train registrars. They must also be available for telephone conversations with their rural colleagues around the clock.

There are still gaps in the excellent twinned arrangements between metropolitan and rural services funded by the Commonwealth. These services—all services, metropolitan and rural—need more hours to be able to teach GPs the basics of palliative medicine. They need more hours to visit aged-care facilities and to consult and teach and do the same thing in those acute hospitals which do not have their own palliative care teams. Unless each group of new residents and interns, as they change turns three or four times a year, get a palliative care input, there will continue to be terrible suffering in the acute hospitals, just out of ignorance.

Palliative doctors are also needed to teach other specialties so that everyone understands symptom control, end-of-life care and other principles of support. The situation in nursing homes is Dickensian. Some of the most difficult cases—you have been hearing about dementia today—are managed by the least trained staff: little girls with six weeks training and no concept of real care. Yet it seems that these places are to be the new hospices and the now hospices are to become only acute short-stay facilities. This attempt to save state funds and shift costs onto the Commonwealth should be resisted to the death.

All palliative care services, both metropolitan and rural, need adequately funded positions to be able to consult and teach in nursing homes. I commend to you the submission of the awkwardly titled Australian Association of Social Workers NSW Palliative Care Social Work Practice Group on this and many other subjects. It comes from many social workers with a wealth of experience who have seen a great deal of preventable suffering. I entirely support ANZSPM's recommendation that every level 3 palliative care service have a palliative care nurse practitioner to oversee palliative care and end-of-life care in nursing homes in its area.

However, I also approve of the excellent development suggested by HammondCare of having palliative care suites within nursing homes, and I can tell you more about that. I commend both approaches to you. Palliative care must be core business for all aged-care facilities, and should be required for their accreditation. As you know, the majority of people wish to die at home. Palliative care community services need more trained specialists—medical, nursing and allied health. They must have, at a very minimum, 24-hour cover—but, even better, is access to nurses who can come to the home in the night when things get scary and carers panic and call triple-zero. This is a great cost saver but, more importantly, it is a wonderful help and support to the people out there.

Some services, I am told, use private nurses who have been trained to understand palliative care, and they have found this to be cost-effective. In the UK they have access to night nurses for the last five days of life. At the present time there is not a single highly-qualified palliative care specialist working full-time in rural or regional New South Wales. There was one superb woman in Lismore for many years, Dr Joanne Doran. She had no registrar and no increase in resources, notwithstanding pleas, in 12 years, despite an enormous increase in workload. This is an utter tragedy for several reasons: first, for the patients; second, because there is now nobody qualified to teach palliative medicine up there; and third, because the opportunity was lost for 12 years of having a rotating registrar position with a top-quality supervisor giving trainees a taste of country life and making it possible that we might attract them to other country centres. This individual could be a marvellous resource to this committee. She is the sort of charismatic leader we need to attract people to the specialty, and she could really advise you.

The situation in rural New South Wales is perilous. Rural people do it tough already, having reduced health outcomes in terms of diagnoses, mortality, access to services—but then, worse care when they are dying! That is inequality to the very end. With no regional palliative care specialist, the medical workforce is made up of GPs—some very good; others not so. A proportion of the GP workforce is made up of overseas born and trained doctors with no palliative care knowledge or understanding or willingness to take advice from specialist palliative care nurses—'You make too much fuss about dying; you have to expect to suffer', one nurse was told. Another nurse wrote, 'GP competence in palliative care in rural areas is vital but sadly lacking.'

What is needed now is a palliative care project manager in every Medicare Local, to ensure that palliative care has the right priority for the community. There are many things that that project manager could be doing. The rural nurses are overworked and overstretched, and many are approaching retirement age. They are holding on by their fingernails, doing a magnificent job—trying to teach the GPs, having to do battle with them; most have no office back-up and no relief; the conditions are almost Third World.

We need more social workers throughout rural New South Wales to ensure that the psychological, social and clinical needs are met. There is a big role for case coordinators, and social workers are filling in some of that, but they need Medicare items for end-of-life and palliative care consultations. That may be something the committee can carry forward.

What I am suggesting for rural palliative care is that 11 major towns in New South Wales be strengthened as palliative care hubs. Each should have funding for a palliative care specialist as soon as one can be found. We should be recruiting for palliative care specialists for these towns from the UK and New Zealand. I am told, however, that services are required to have six failed attempts at recruiting within Australia before they are allowed to recruit overseas. It seems to me a good way to put off having to spend any money. Can you put a stop to this?

There may be a role for practice nurses in the country. These are employed by GPs and can be trained by palliative care teams or they could do a PEPA course. Then they need Medicare items for palliative care consultations and doing care plans, but they would be good to link with the palliative care services and palliative care practices—it could work. The Commonwealth must improve access to community help services such as HACC, and I would love to talk more about that. By the time they kick in now, the patient has usually died. It would save squillions in hospital admissions.

I have not written very much about Indigenous specific issues, because I do not have direct personal experience, but I have had contact with quite a few of the practitioners out west. They say to me, 'Every mob is different; and rural, regional and urban are different, so we can't generalise.' I was hearing the questions. The burden of many deaths in the Aboriginal community, and the resultant grief, is huge and it needs to be addressed. Aboriginal liaison officers, and Aboriginal health workers, are the bridges—and bridges are needed. But they need training and support in palliative care, and they do not have it. The Closing the Gap project could have palliative care targets and promotion. Care coordinator positions within that project should be linked to palliative care services, but they are not. Thank you.

Senator MOORE: There is so much in that, Dr McMaster—

CHAIR: Where do you start!

Senator MOORE: Yes. We will have all of that in Hansard, so we could well be sending follow-up questions to you.

Dr McMaster : I would be very happy with that.

Senator MOORE: You have raised a lot of issues from your experience, and made a lot of recommendations, both in your written submission and in what you have said to us. Beyond the fact that there needs to be more resources—that is clear—what would be your priority in terms of reforming the system, having worked for so long within the state system? I take it that was all in New South Wales?

Dr McMaster : Yes, it was.

Senator MOORE: Yes, you make comment about that all the way through. What do you think, as the government is putting together a new process and all those sorts of things, should be the priorities?

Dr McMaster : Rural areas are in the greatest need. But I do not think you can do much for the rural areas unless you can get palliative care doctors in those key towns. At the moment the rural areas are dependent on the fly-in fly-out services for specialist doctors' help. They deal with the really difficult clinical problems that occur—and there are some difficult clinical problems out there—and they are needed for that. But they are stretched too tight now, so they are not able to visit as often. The girl who used to go down to Moruya cannot go as often as she would like to. She has trained up the local GPs quite well in her time, but she will still be needed for the acute, difficult stuff—and yet the time is holding her back. That is happening all over the state. And the service is not uniform anymore—not every area is covered, so there are still towns and big areas that are not covered by the fly-in fly-out services.

Senator MOORE: So when you say 'palliative care doctors', what constitutes, in your opinion, someone who could take that title?

Dr McMaster : Now we use that term for people who have trained either in the Chapter of Palliative Medicine or with the College of Physicians.

Senator MOORE: Right. So there is the post-graduate qualification—is it three years?

Dr McMaster : Three or four.

Senator MOORE: Yes, so you do your basic degree, your residency then a period, after which you have a focus for three years to get your full qualification as a physician with a palliative care focus.

Dr McMaster : It is quite arduous.

Senator MOORE: It is a long time—that would be 10 years maybe. You came in at the very start. How attractive is that to young doctors now with the range of need that there is?

Dr McMaster : There is a problem, and that is women. We are the problem because of course we are more attracted to this sort of work and yet we will go and have children, won't we?

Senator MOORE: Awkward, yes. So taking you out of the mainstream.

Dr McMaster : And then we also want to work part time which does not make it easy, but there are women doing it and there are men doing it and people are attracted to it. I feel it has been a major problem. There has been a tremendous contraction in New South Wales over the last 15 years—really since I retired; nothing to do with that of course. It has been so sad to see that services which were flourishing and people coming in were very interested to do palliative medicine are not doing as much now. I think if people stop being so demoralised—that is where I think money will help.

Senator MOORE: You have mentioned that a couple of times: the demoralised workforce.

Dr McMaster : It really has been that.

Senator MOORE: And feeling unvalued.

Dr McMaster : They are not paid as well as procedural specialists of course but they can be better recognised in pay. There could be specific item numbers such as the geriatricians have. They have a very good item number for a very complex assessment. There could be item numbers like that for palliative medicine, because most of palliative medicine is complex assessments.

Senator MOORE: It is balancing that, and this morning one of PCA's concerns was activity based funding on the basis of how you define activity in this field because you are working with a patient. You are working with their family. You are working with their next-door neighbour. You are working with their nurse. How do you count that? And I do not think we have got our heads around that yet.

Dr McMaster : I don't either, and it is a great worry to me because in New South Wales things are so contracted now. There is not much activity, so how do you ever justify your need for a whole lot more?

Senator MOORE: You just buzz around.

Dr McMaster : I am trying to ask New South Wales to give us $50 million straight off but I do not know if they are going to do it. I am going to try very hard.

Senator MOORE: It is worth a try.

Dr McMaster : Yes.

Senator MOORE: So you think it is building up your resource base and then rebuilding the focus.

Dr McMaster : I believe that we could really do something dramatic in the country if we advertised overseas and got people in the rural towns. They would then have to have a rotating registrar coming from city practices backwards and forwards every term, and all those young doctors doing palliative medicine would have the experience of country life because attracting people to the country has been hard.

Senator MOORE: So your view of telehealth in this sphere is that you could have face-to-face contact with who you need but by screen.

Dr McMaster : I think it would be a big help, but real medicine means examining patients.

Senator MOORE: Touching and feeling.

Dr McMaster : I know people like to do CAT scan and things, but you really cannot do it terribly well unless you are right there.

Senator MOORE: There has got to be a body.

Dr McMaster : Yes.

Senator MOORE: I think this morning someone was talking about the fact that telemedicine is fine in this sphere as long as you are talking to another professional at the other end.

Dr McMaster : That is great.

Senator MOORE: So that if you have someone from a larger area who has been trained to a level—and I will not mention New South Wales names because I will get it wrong and they will not consider themselves regional and I will offend them—in a regional New South Wales centre they do not need to be talking to the family direct; they need to be talking to the family with someone like a palliative care trained nurse or someone like that.

Dr McMaster : Yes, that would be great. It is not as good as having—

Senator MOORE: People.

Dr McMaster : a palliative care specialist in that town who is educating the GPs, educating the nurses and getting more attention for palliative care in the community so that people start to understand it. I think that would make such a difference and where, for instance, Joanne Doran was so successful in Lismore. It was just wonderful.

Senator MOORE: Lismore is a significant centre too, and we all know Lismore is closer to Brisbane than it is to Sydney so that is the other issue about where the—

Dr McMaster : There are cross-border issues everywhere.

Senator MOORE: Where is Joanne now?

Dr McMaster : Good question. She is doing a locum in Townsville. I spoke to her a few days ago.

Senator MOORE: We were just there yesterday.

Dr McMaster : Really?

Senator MOORE: Doing our other inquiry on rural health.

Dr McMaster : I am trying to nab her as well. Anywhere we could get her would be great.

Senator MOORE: She will do well up there if she likes the heat. Doctor, where you here when we had LifeCircle talking about their projects?

Dr McMaster : Yes, I was. I know them. I have experienced their services. They are a very good body. But I have had very few of my cancer patients wanting to have their help, because there is a barrier somehow to having another person on the team. So it has been a pity, because I have kept promoting them to a number of my carers.

Senator MOORE: There is their model of the life matter seminar type of approach of bringing people early into the general discussion. Have you been able to see any of that at work?

Dr McMaster : I have.

Senator MOORE: And what is your view from your experience?

Dr McMaster : It is really great.

Senator MOORE: And the medical profession support that?

Dr McMaster : I am sure. Yes, no trouble.

Senator MOORE: Something else danced into my brain but now it has danced right out. I will get back to you when it comes back.

CHAIR: Senator Fierravanti-Wells.

Dr McMaster : I am very interested to speak to you, Senator Fierravanti-Wells, because you are the shadow ageing minister.

Senator FIERRAVANTI-WELLS: Picking up your point about regional towns, recently when I had my fracture it was interesting and I am happy to share this story. I had a wonderful orthopaedic surgeon from Royal North Shore who looked after me. I went out to Dubbo one evening to do something and there was the doctor on the same flight as me. He was going out to do his rounds. I am sure he will not mind me saying that Dr Stephen Ruff is a fantastic orthopaedic surgeon. I see nods. He will be really embarrassed about this. It was fantastic to see the work that they were all doing up there. Of course, so many of these regional centres would not survive, whether it be orthopaedics or any other area, without the fly-in fly-outs. The doctor was doing his orthopaedic rounds for a day. There were a number of other practitioners on that flight who were doing exactly the same thing, so it is clearly a feature. So you would see your specialist palliative care positions as being an extension of that sort of program?

Dr McMaster : Absolutely, and that exists now. There are city hospitals that send people to Dubbo, to Wagga, to Albury, and I think that is it—not enough.

CHAIR: Dubbo, Wagga and Albury—so nothing up north really. Dubbo is a bit so but not up to there.

Dr McMaster : Actually I should not fudge it because Hunter-New England goes well north.

CHAIR: Yes, that is right.

Dr McMaster : The Hunter-New England palliative care service is run from Newcastle and so they look after that, so they visit Tamworth and so on.

Senator MOORE: And Armidale?

Dr McMaster : I do not know if they go as far as Armidale, but they should.

Senator MOORE: It is a significant centre.

Dr McMaster : There should be a specialist in Tamworth. There is a doctor in Tamworth and I still call him a palliative care doctor, very much so. There is this snobbery now about people who have got a college degree or a chapter degree or about those like the doctor up there who is very good and devoted and works seven days a week but has come up from being a GP and trained somehow, and I do not know what training he has had. But they will not, for instance, let him have a registrar, because he would not be qualified to supervise a registrar.

Senator MOORE: Or a clinical placement of any kind?

Dr McMaster : Yes.

Senator FIERRAVANTI-WELLS: In terms of your point about geriatricians and speaking from personal experience as to my father, it took me three months to get an appointment with a geriatrician in the Illawarra. They are like hen's teeth, I am told. I guess this is really what it has brought home to me: how do we in an ageing society deal with this when all the specialties in our society such as geriatrics and geriatricians—so those specialties which deal with older Australians—are so much in demand and yet I think we could probably count—I do not know, so tell me—on two or three hands the number of geriatricians that actually practise in New South Wales. That is the experience that I have had. It is a real challenge—how are we going to do this?

Dr McMaster : One of the solutions that people are pointing to—the nurse practitioner one, where ANZSPM recommends nurse practitioners visit nursing homes—is a very good suggestion and very low-cost.

Senator FIERRAVANTI-WELLS: Mobile services—is that what you are thinking about?

Dr McMaster : Nurse practitioners have quite a high qualification in nursing and can, in fact, do minor prescribing, diagnosis and so on.

Senator FIERRAVANTI-WELLS: But as a visiting nurse practitioner to a particular aged-care facility or embedded in the—

Dr McMaster : Aged care, yes.

Senator FIERRAVANTI-WELLS: Visiting aged-care facilities?

Dr McMaster : Visiting.

CHAIR: They would have an area and they would have a number of residential homes under their auspices, is that what you mean?

Dr McMaster : Yes.

Senator FIERRAVANTI-WELLS: Under their auspices, where they would go in with appropriate MBS items, they could do so much more. Ultimately Dr McMaster, and correct me if I am wrong, one of the issues is Commonwealth versus state and then aged-care facility. As I see it, part of the problem is that, when you have the services coming via the states, you will always end up having an additional bottleneck, whereas if the funding is directly from the Commonwealth to the residential aged-care facility you not only give them viability and flexibility, but you also give them a better and much more cost-effective service.

Dr McMaster : That is right.

Senator FIERRAVANTI-WELLS: Would you see that as being separate under Medicare or part of an ACFI tool? What are your thoughts on that?

Dr McMaster : I am really unimpressed with what the Commonwealth government has done in terms of funding GPs to go to aged care.

Senator FIERRAVANTI-WELLS: That has not worked. We have had various incentives—

Dr McMaster : We had the panels initiative. The panels initiative was working. It was starting to really come good. In 2008, it was cut and replaced with an aged-care access incentive package, which was said to be better. But the GPs tell me it is not better at all. It gives them a little bonus if they get a certain number of visits to a nursing home, but there is no way that compensates them for the time it takes to do these very complex assessments in nursing homes, particularly of demented people. It is all very complex medicine that they are having to do. Instead of sitting in their surgery and seeing one patient after another for five-, 10-, or 15-minute consultations and syringing out an ear or looking at a child's throat, they have got to lump themselves over to the nursing home for two hours and see maybe half a dozen patients for nothing like they would charge at the surgery. The Commonwealth could not pay them for it.

Senator FIERRAVANTI-WELLS: The only place where I have actually seen the visit work successfully is where you have got a practitioner that has an arrangement with an aged-care facility where they end up doing 10 to 12 visits a day. Do you think the concept of paying a retainer can have some validity in the aged-care setting? It works well in the legal profession. The concept of a retainer—have you seen that operating at all?

Dr McMaster : I am very interested in this at the moment. This is just fantastic timing. You know Mary Gaudren, of course, the former judge. She is extremely interested in aged care and palliative care, particularly aged care and what is happening in the nursing homes. I thought I might be able to enlist her help with palliative-care advocacy, but I think she has enlisted mine in aged-care advocacy. We have been looking at what can be done, because she has seen from her personal experience how bad things are in aged-care facilities. We are very, very pleased to see the changes that the new releases from the last couple of weekends. I have not yet seen the detail of that. I would love to though, if Sandra could send me the link that would be fantastic.

CHAIR: She will send you the link if you send us some comments back on what you think.

Dr McMaster : Anything you like. Yes, of course I would. We are talking to a lot of geriatricians and one geriatrician I spoke to recently is a retired one who I think would help us with our advocacy. She said she does not at all like—she has seen it work very badly—to have a GP tied to a nursing home. She did not think that this worked at all well—the standard of medicine just went downhill.

CHAIR: You mean a retainer or somebody who is actually part of the support?

Dr McMaster : Maybe I do not fully understand the concept of a retainer.

Senator FIERRAVANTI-WELLS: A retainer is, for example, where a local practice is paid a certain amount per annum by the aged-care facility. There is an arrangement, basically, to provide a service there and to cover all the patients. But what you are saying is that one GP having all the patients in an aged-care facility does not work.

Dr McMaster : It does not work. What we have been looking at, talking to a lot of geriatricians, is what would be a better way to provide medical service. There was a fellow called Dick Jeeves, who was one of the first geriatricians, who introduced in the Hornsby area a course for general practitioners who were interested in aged care. They came to meetings and didactic talks and went on ward rounds with geriatricians and so on for about six months. These people did not get any extra qualifications or anything, but they had the interest. Because you have got to know a lot to have mastery, otherwise you are swamped. You walk into the nursing home and your brain goes dead when you see these horrors. The terrible things that go on—the clinical problems that are so bad. That has worked really well for a number of years, but it has died out. The doctors are dying out now. They have almost all retired, the ones that came from that. HammondCare has got a university going—maybe it is at the University of New South Wales that there is—

Senator FIERRAVANTI-WELLS: I thought it was with another university. I did not think HammondCare had that.

Dr McMaster : There is Professor Chris Poulos who is a professor for good ageing or something like that. It sounds ideal. He and HammondCare are interested in having a master's degree for general practitioners in aged care. It is not the same as being a geriatrician. It would not be as arduous to do, but it would give them the skills and the knowledge. They would have palliative care training. They would have psychogeriatric training. They would have geriatric training. I cannot think what the fourth is at the moment, but I can let you have all that stuff. That is almost off the ground. This is perhaps a way where we can have GPs having a bit more status, because they can call themselves something. They will have to ask for different item numbers, of course, to visit. They would have the job satisfaction of feeling that they are doing the right thing—that they are actually able to do something. Everyone used to say, 'Isn't it depressing doing palliative care?' It is not. It is the most wonderful thing, because you can do so much to help. Maybe the same thing applies to geriatrics. Maybe you really can do a lot to help. It is just that I get depressed when I see people lying around with gangrenous feet and unable to talk to me. There must be satisfaction there somewhere.

Senator FIERRAVANTI-WELLS: Food. Look, I will not go the food route in aged-care facilities, but—

Dr McMaster : It is terrible, what is happening.

Senator FIERRAVANTI-WELLS: Can I just ask a basic question. When you are 85 and you are sitting in an aged-care facility, if you want strawberries for breakfast, why can you not have strawberries? I cannot understand that whole issue with food in aged-care facilities.

Dr McMaster : Absolutely.

Senator FIERRAVANTI-WELLS: The concept of a boiled egg in aged care facilities just blows my mind. An egg has to be boiled to a certain temperature. It is like a piece of rubber; it is not a boiled egg.

Dr McMaster : The whole thing can be greatly improved, can't it?

CHAIR: We should probably go back HACC.

Senator FIERRAVANTI-WELLS: I have one last question. Before Senator Siewert asks about HACC, you made a comment that if you get them and give them the care when they need it you will save squillions in hospital care. You mean, obviously, some sort of assessment process for receiving services but to loosen that on an as-need basis? The Productivity Commission talked about an entitlement. You think if you were to loosen that up that ultimately you would have a lot less hospital admissions?

Dr McMaster : Yes, of course, because that is really what is needed. I just had an enormous number of palliative care nurses throughout New South Wales corresponding with me when I was making the submission—and also we were trying to influence the state government. So they told me all these things. HACC came up all the time. The need for home care services is enormous, but the problem is palliative care does not qualify because it is not aged care. Anyway, if an aged care does not qualify, because it still takes six months to get the service.

I tried to follow this up with the Department of Ageing and Disability in New South Wales. They told me that there is a small window of improvement happening in Hunter/New England, where they have got the ability to supply their home care packages a little bit sooner than the six months, because that is what is needed for palliative care. You have got to get those services in before the person actually dies.

We heard the nurse earlier say that you need three able-bodied people to look after someone dying at home. You do not need three if you actually have a home care service that will come and give the person breakfast or make the bed or make sure they have taken their pills at night—that sort of thing. That is what home care can do: really sensible, basic stuff that the daughter used to do—the daughter whose boyfriend had been killed in the war; the maiden daughter. We do not have those anymore.

CHAIR: Can I go onto the issue around HACC. B asked the department this morning and they sort of said, 'Yes, you can get some funding for palliative care.' But I think I need to put some more questions on notice.

Senator MOORE: It is federal funding operated by the states, so it is how the states determine it operates.

CHAIR: That is my concern. It seems like we have different rules for different states, and New South Wales seems to be harder, perhaps, than other states.

Dr McMaster : Is that right? I do not know.

CHAIR: So we need to write around to each of the states and clarify exactly what you can and cannot get under HACC, because you are right: it is the timely agreement that you can have services.

Dr McMaster : There are very good people working in HACC and in COP—Community Options, I think they are called. They are very dedicated people trying really hard without enough funding. That is the problem. They are struggling. They are working very, very hard to keep people out there.

CHAIR: We will definitely chase that up.

Senator FIERRAVANTI-WELLS: I asked questions about this at estimates. I have asked in particular, with the takeover of HACC at the federal level, whether they were going to do a bit of a stocktake of what the services are. They must have done some of this work—

CHAIR: My understanding is that they have.

Senator FIERRAVANTI-WELLS: as a consequence, at least in response to the PC.

CHAIR: The other thing, of course, is that the complicating factor is for those that need palliative care that are not over 65. Now we have this split between state and federal. We have to clarify that. If you are in need of palliative care but you are under the age of 65, you do not qualify necessarily for disabilities, which is now a state responsibility. So we will follow that up.

Dr McMaster : Great. That would be fantastic. Well worth it. Those girls out there will praise you.

CHAIR: Thank you. We started a bit early so we are finishing on time. Are there any other following questions?

Senator MOORE: Dr McMaster, we may well be in contact with further questions that come out of discussion, particularly when you come back with any comments about the changes last week and about how they can operate or not operate. There could well be an interchange from then on.

Dr McMaster : Through Sandra.

Senator MOORE: Yes.

CHAIR: That would be very much appreciated. Thank you for spending the day with us—you have been here nearly all day.

Dr McMaster : I would love to hear them all. Are there more coming?

CHAIR: Yes, but not until July, because we are now just about fully committed with other things up until the end of parliament's sitting in June. I am pretty certain it is in the first week in July that we have some, and then the following week we have a couple more.

Dr McMaster : Maybe I will book to come down for a week.

CHAIR: We will let you know. It will be on the website in the not-too-distant future. We have not decided what we are doing. We have booked in the days but not the itinerary yet. It will be on the website, or you could give Sandra a ring and she will be able to tell you where we are going on particular days.

Dr McMaster : That mass of submissions is a great resource—a fantastic resource—for me and for NSW Health.

CHAIR: That is the beauty of these sorts of inquiries.

Dr McMaster : Wonderful!

CHAIR: If you go to the other inquiries we have done, we have hundreds of submissions that contain such excellent information. I would point a lot of community members to just go and look at the submissions if you want to know about this particular issue. You can find out heaps.

Dr McMaster : Thank you so much.

CHAIR: Thank you.

Committee adjourned at 17:11