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Community Affairs References Committee
11/05/2012
Health services and medical professionals in rural areas

GREGORY, Mr Gordon, Executive Director, National Rural Health Alliance

HANDLEY, Ms Anne, Policy Adviser, National Rural Health Alliance

HOPKINS, Mrs Helen, Policy Advisor, National Rural Health Alliance

[11.54]

CHAIR: I understand information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. We have your submission; it is No. 95. I invite you to make an opening statement, and then we will ask you some questions.

Mr Gregory : Thank you for inviting the National Rural Health Alliance to appear before the committee. The topic of this inquiry is absolute core business for the alliance. The first part of the terms of reference could pass as a synopsis of the alliance's very purpose:

(a) the factors limiting the supply of health services and medical, nursing and allied health professionals to small regional communities as compared with major regional and metropolitan centres;

We therefore want to thank you for initiating this inquiry and for the energy you continue to display, including at the public hearings you have held in Alice Springs, Darwin and Townsville. At those public hearings, members of the committee heard directly from organisations and researchers with detailed knowledge of the challenges of providing health services in remote areas.

Today in Canberra you are speaking separately with some of the alliance's member bodies. In a supplementary submission which we hope you will accept, we emphasis high-level or strategic points and also, because we think it incumbent upon us, given that this is our core business, to produce some specific recommendations, we have attached to that supplementary submission a document modestly entitled The NRHA's 20-Point Plan for improving health services and health workforce in rural and remote areas. May I formally table the supplementary submission, Chair?

CHAIR: Yes; thank you.

Mr Gregory : The six strategic issues in that document are: (1) the importance of being faithful to the terms of reference and recognising the full range of health professionals providing front-line services in rural and remote communities, (2) the urgent need to obtain the datasets needed for overcoming the factors limiting supply of health services and health professionals in rural and remote communities, (3) improving on the ASGC-RA classification system, (4) the pros and cons of a universal health service obligation, (5) the role of rural and remote health and medical research in informing and implementing health policy reforms in rural and remote communities and (6) the relationship of your inquiry with other activity.

The first issue is greater equivalence of support for all front-line health professionals. Among the distinctive features of the best health service delivery in rural areas is a team approach to care. GPs and other health professionals do not want to work alone in rural areas; they prefer to have peers with whom responsibilities can be shared and a range of other health professionals with whom they can work. In many areas, general practitioners are the coordinators of care for individual patients, and they are frequently the leaders of action related to the health of the local community. The rural and remote health workforce relies heavily on nurses on the front line, including where doctors are scarce. Multidisciplinary or, better still, interdisciplinary teams—often brought together by phone or video, or by driving in—become more important for health service provision as the population becomes more sparse.

The terms of reference for this inquiry speak, properly, of 'the supply of health services and medical, nursing and allied health professionals'. To these could be added Aboriginal health workers, pharmacists, dentists, paramedics, midwives, chiropractors and health and aged-care service managers. We are confident that, in its report, the committee will include whatever recommendations are necessary to ensure that the inquiry makes a significant contribution to health service and health professional availability across the board in rural and remote areas.

The second strategic issue is data. For too long there has been uncertainty about the actual full-time equivalent supply of doctors to rural areas and the number of doctors in practice compared with the number needed for fair access. There have also been a variety of understandings of 'rural and remote'. Thanks to our friends at the Australian Institute of Health and Welfare and Health Workforce Australia, and the work of the Australian Health Professionals Registration Authority, we are closer to being able to report accurate figures for the numbers and distribution of doctors. We may soon have better information for nurses and allied health professionals as well, but the historic data is not clear cut for nurses and has been highly deficient for allied health. Given the close relationship between the numbers of professionals and the supply of health services in any particular area, it will be critical for your report to make recommendations on what might be called the health data system, in which those three agencies and a number of others are involved. Those others including in the COAG Reform Council and the National Health Performance Authority.

The alliance would like Health Workforce Australia to fund the Australian Institute of Health and Welfare for some particular projects that relate closely to your terms of reference. These projects could include better and more regular reporting for allied health and joint projects between Medicare, PBS and the AIHW to compare rates of utilisation of NBS and PBS services across areas by remoteness. We believe there is still a need for more detailed analysis of full-time equivalent doctors and other health professionals by geographic location.

The third strategic issue is ASGC-RA. The Australian Standard Geographical Classification or Remoteness Areas classification system should not be used on its own for the identification of rurality, for the distribution of financial incentives or for the return of service to rural or remote areas under various student bonding arrangements. There should be one simple approach to the assessment of health workforce shortages, which could in the long term help provide greater equivalents of support across the professions.

The alliance has been working on a composite measure, which would include three criteria for any particular place. It is ASGC-RA classification, it is population size and an index reflecting its success in the past in recruiting and retaining health professionals. This last is a proxy for the range of variables which results in a particular place being one to which it is easy or difficult to attract and retain staff. Many of the alliance's member bodies have approved this approach, while some others with particular interests in the matter have sought further conceptual work, modelling and more time prior to any public promotion by the alliance of the final measure system.

Four, universal health service obligation: we note from Hansard's record of your earlier public hearings that there is some enthusiasm for the notion of a universal health service obligation approach to the planning and delivery of health services, described more colloquially as an agreed basket of services appropriate for different communities. In our supplementary submission, we place on record the reasons why the alliance believe this to be an impractical approach. We seek an appropriate balance of local core services, supported by outreach, telehealth and patient's travel assistance, but effective primary or community care services in rural and remote areas can and should take many shapes.

Fifth, health research: we have already made the point that there are data problems relating to your inquiry's terms of reference. For instance, little is currently certain about the impact of the introduction of Medicare Locals on the provision of health services. This week's budget announcement about incentives for dentists to relocate to rural and remote areas is very welcome, but little if anything is known about the specific issues which might affect the mobility of dentists, let alone retaining their services in rural and remote locations.

The McKeon review will hopefully conclude, among other things, that there needs to be greater research effort on rural and remote aspects of the national health system and that it should include more upstream research on the social determinants of health and more downstream research on health service systems and approaches. As a nation, we need it to apply an evidence base to choices made between policy options just as we have and need an evidence base on illness and disease.

Six, relationship of your inquiry with other parliamentary and governmental activity—that is the heading. I want to make the point that the subject matter of this inquiry overlaps with a number of other pieces of work recently completed or currently in train. In particular, the recommendation from your colleagues in the other place, relating to overseas trained doctors, should be integrated with your own considerations.

The Department of Health and Ageing is beginning another review of its workforce programs. Health Workforce Australia is engaged, as you know, on a number of fronts that are relevant to your inquiry. The alliance for which we work has a considerable number of relevant documents about these matters on its website. I think that is the point where I should apologise, possibly to your secretariat, for the weight of our submission, because we provided a great deal of documentation for your inquiry but that reflects only the fact that, as I have said, it is core business for the alliance.

CHAIR: I should say that our committee gets a lot of documentation, so we have pretty high benchmarks for weight of documentation.

Mr Gregory : Thank you so much. That is splendid. As to the 20 steps to equal health—this is in summary and the detail of these points is in the supplementary submission which we tabled—the 20 points are: (1) getting more rural students into health professions; (2) getting more health students to undertake rural placements while in training; (3) getting more Aboriginal and Torres Strait Islander people into the health workforce; (4) ensuring positive modelling and leadership on rural practice for tertiary students; (5) promoting knowledge of the various rural incentives available, and of the positive elements of rural practice, to late-year undergraduates and new graduates; (6) creating a greater proportion of supported placements for new health graduates that can be undertaken in rural and remote areas; (7) increasing the proportion of vocational training for health professionals that is undertaken in rural and remote areas; (8) enhancing the capacity of existing practitioners in rural areas to accommodate, mentor and supervise new graduates and vocational trainees; (9) extending the coverage of university departments of rural health; (10) balancing incentives for health professionals to train for generalist rather than specialist practice; (11) targeted infrastructure and human resources programs to maximise the opportunities for use of information technology in health, including as back-up to training and mentoring of health professionals in rural areas; (12) enhanced support for the role and capacity of rural workforce agencies; (13) national leadership on work to ensure health practitioners are able to work collaboratively and maximize their individual contributions within their full scope of practice; (14) refurbishment of the whole recruitment and retention program for health professionals to ensure its effectiveness for places in particular need and for the new generation of practitioners; (15) ensuring that the funding and governance of Medicare Locals equips them for their role in the identification of service gaps and provides them with the wherewithal to fill those gaps; (16) greater involvement of governments in special cost-sharing arrangements for salaried staff in areas of very particular need; (17) working with professional colleges to ensure that mature-age clinicians willing to work part-time as mentors and preceptors are able to do so; (18) improvement of national data collection and analyses; (19) increased emphasis on health service system research for rural and remote areas; and (20) continued national commitment to building universal schemes for dental care and disability.

Senator DI NATALE: I am interested in the Medicare Locals issue, just following on from Senator Moore, because I know there is some concern from the Rural Doctors that the Medicare Locals might act as fund holders and regarding the role of GPs on the boards and so on. They have expressed a number of concerns around Medicare Locals regarding accountability and so on. What is the alliance's view of the potential for Medicare Locals in regional Australia?

Mr Gregory : There are, as we said, major expectations of them, but we believe that they are real, they are with us, they are happening, and we should be taking every opportunity to make it work in rural areas. There are a lot of issues—not only those you have identified which come particularly from the doctors. There are issues relating to size, for instance. The whole of the north of Western Australia is one Medicare Local, as you know, and the whole of Tasmania is one. There are lots of issues but we, the alliance, take the view that this is, if you like, the focal point now of all the effort that has been put into health reform over the last three to five years and we want to make every effort to make it work best for people in rural and remote areas. We had a workshop about two weeks ago jointly with the Australian Healthcare and Hospitals Association on this very subject, and I would commend to you the report from that workshop, which will be out in a week or two.

Ms Handley : It was also a wonderful opportunity that we have not had before for some cross-border issues to be resolved. For instance, Finley, Jerilderie, Berrigan and Tocumwal are in one Medicare Local that is shared with and feeding through Goulburn Valley Health, and that has always been the natural flow. It has always gone south. So even though Berrigan, Finley, Tocumwal, Jerilderie and, to a point, Urana and Deniliquin were feeding hospitals geographically when they were Greater Southern or Murrumbidgee, or whatever we were last, the given hospitals were Griffith and Wagga, but neither the ambulances nor the patients wanted to go there, so the general flow was south. That is a real opportunity around this cross-border—

Mr Gregory : So it is across the river. You get the point, I am sure. They go to Victoria.

Senator DI NATALE: Yes, it is a very frustrating situation.

Mrs Hopkins : And, more generally, it is just to get that involvement of local people in what local health service needs are and what the solutions might be so that they will work.

Senator DI NATALE: Do you have concerns about them essentially becoming just rebranded divisions of general practice?

Mr Gregory : We trust they will not, because the very essence of their success will be that they are much broader than general practice. That is one of the main challenges, as you perhaps indicated through your question. We have to make this work. We are concerned, I think, about high order issues like the relationship between Medicare Locals and local hospital networks in rural areas. It seemed to us initially to be a bit strange to institutionalise the difference between acute care and primary care given that, especially in more remote areas, you have the same clinicians working in both sectors. But we accept the logic that it is to make sure that the hospitals do not gobble up all the resources—put crudely.

Senator DI NATALE: You mentioned in point No. 20 you are committed to universal dental care.

Mr Gregory : Yes.

Senator DI NATALE: I am very pleased to see that as one of your recommendations. Recently a package of measures was announced, one of which included some relocation grants. I think the target was 300 dentists to regional Australia. Is there anything else you think could be done as a short-term measure to increase the number of dentists to regional Australia? I think the obvious immediate policy lever is incentive payments. Is there anything else that could have been included as part of that?

Ms Handley : It is very expensive equipment. I will go back to the example of Berrigan. There is a public health dentist there for, I think, one day a month, and they are always booked out years in advance. The dentist there said to me that he would be much better off having a mobile van and moving around, like the old school program did, to give more people access and not duplicate the very expensive tools of trade that they have.

Mr Gregory : As well, we see no reason why HECS reimbursement should not be available to students of dentistry, and indeed allied health and nursing, as well as medicine.

Senator NASH: Just on Medicare Locals, the Rural Doctors Association raised in their submission—and we did not have a chance to ask about this—that the incentive payment available in the PIP After Hours Incentive will now be redirected through Medicare Locals. They had some concerns about Medicare Locals administering the funding. Is that a concern that you share or are you comfortable with the fact that administration of the funding will now go through Medicare Locals?

Mr Gregory : Our broad view is that, given one of the key expectations of Medicare Locals is that they will identify gaps in service and then move on to fill by whatever means there is, the alliance broadly approves of the possibility that funds might be held by Medicare Locals in some circumstances. As you can tell, I am being fairly nuanced because the organisation you mentioned is one of the member bodies in the alliance. If we are serious about Medicare Locals, as I hope we are about Medicare Locals identifying gaps in service and filling them, I would have thought the health consumer would be pleased if that is done by whatever means, irrespective of who holds the funds, where they come from, how they flow. Let's meet the need. As Helen said, let's identify the local need and meet it by whatever means.

Senator NASH: Would it be fair to say that for Medicare Locals at the moment there is a lack of a clear picture? With the questions we have asked in the past there has been a lack of a clear picture of exactly how they are going to work. If it all goes well, it is going to be terrific; but there is a possibility that it may go pear shaped and will not be as good as it possibly could be, and that we are all just hoping it will work really well.

Ms Handley : One of the biggest things that one particular person and one doctor brought up was that we have just disbanded 15 or 20 years of goodwill between the divisions of general practice, so if it does not work it is going to be bigger than Ben Hur.

Senator NASH: It is high risk, really, isn't it?

Ms Handley : It is very high risk. The other thing is that if you talk to the different members on the boards of different Medicare Locals and ask them questions, the actual make-up and the set-up of how they are organised is very different. There does not seem to be a uniform scaffolding that everybody sits on. To me, that is the most worrying thing.

Mr Gregory : I think it is likely in five years time when we look across the Medicare Locals that we will find there is just the range of effectiveness and noneffectiveness, as there was with the divisions. With the divisions of general practice, some of them were good and some of them were not so good. Some of them were not so good at all.

Senator NASH: Does that lack of a template, for want of a better word, give too much autonomy to the Medicare Locals to set things up and run things how they want or would that have a benefit in giving them a bit of a blank page to have a look locally at what needs to be done and purpose build that for themselves?

Ms Handley : I think it all depends on what sort of information there is. I have had a lot of GPs ask me what I know about the Medicare Locals. For instance, at the moment they might have a diabetes nurse in their clinic who is the only one in the town. Will they lose that person and have that resource taken away from them because this is a more attractive thing that is going on than in the GP clinic? If we have only a given number of physiotherapists, allied health people, psychologists et cetera, are they all now going to be torn between too many places? That is also a fear of GPs—the competition to attract what you need.

Mrs Hopkins : One of the principles that we had in developing Medicare Locals was that it would be very important that they nurtured the people who were already on the ground and worked with them to develop solutions that would keep as many people involved as possible. With the gap in information about how it is all going to unfold it is a nervous time. We, the alliance, are also looking to see how we can play a part with the Medicare Locals, particularly those which might encompass quite large rural areas as well as the city areas, to work out that balance. One reassuring thing is that we will have the healthy communities reports starting to give us some transparency about how it is all unfolding on the ground, remembering that it is a work in progress and that we will have opportunities to come back and say, 'This is not working; we need different solutions.'

Senator MOORE: Ms Handley, I do not understand your last point. If you have a diabetes nurse or a psychologist already in a region, why would a Medicare Locals process make that worse?

Ms Handley : This is just feeding off what the GPs have said to me. If in the gap analysis it was decided that you needed this particular service around psychology or diabetes management and that service was put outside of the GP practice where it is located now and that was the only person in the region would they be losing all the gains they have made by incorporating that person into their primary health care to another part of an organisation?

Senator MOORE: I do not think there is any ability within Medicare Locals to take resources and move them.

Ms Handley : But the GPs do not understand that.

Senator MOORE: A Medicare Local is looking at identifying gaps and what is needed to fill those gaps. If they are saying, 'We have a diabetes nurse in our practice and someone is going to take that diabetes nurse out of our practice and give it to somewhere else,' there is no power for that.

Ms Handley : No, there is not, but these are the conversations they are having. That is how much lack of understanding is out there because of the way perhaps in particular areas it is being delivered to them as GPs. The concepts, formats or understanding of the education around what is happening now that the divisions of general practice—

Senator MOORE: So it is the communication process?

Ms Handley : Yes, it is a communication problem.

Senator MOORE: So it is a build-up of fear about, 'What am I going to lose?'

Ms Handley : Yes.

Senator MOORE: I am very interested in the issue of the ASGC. Are any of you aware of any model that has ever worked in this area of how you define need and remoteness?

Mr Gregory : No, but we, the alliance, think that it should be agreed that the current system on its own does not work and that we should move on and build a new one. You have heard from RDAA that they support the John Humphreys model. What we are proposing is very close to that.

Senator MOORE: So yours is very close to that of Mr Humphreys? You are not going off on a different—

Mr Gregory : No.

Senator MOORE: Okay. Good.

Mr Gregory : We have ASGC-RA and population size of the place, which is basically what John Humphreys has got, and then we are adding a third one which is a proxy for whatever it is that makes a particular place attractive or not attractive, because it is a measure of how they have done historically.

Senator MOORE: Cairns versus Gundagai?

Mr Gregory : You would look at the evidence for Cairns and Gundagai's respective success over the last—choose a number—15 years, and that would necessarily, almost by definition, be a proxy for everything that makes Cairns and Gundagai differentially attractive. So we have this consolidated thing which we think could apply to the measurement of the need for doctors or, indeed, potentially any other health professional if you have the data.

Senator MOORE: It is in terms of the need for everything, which is important. Do you think that can work? We were talking about stats earlier this morning. It was about trying to find out whether you can combine different datasets to come up with an outcome. It seems to me that you should be able to. Do you think that, with the range of knowledge you have and with all the component membership which covers everybody in this field, it could work?

Mr Gregory : We have drafted a look-up sheet, which would be the equivalent thing to what is currently on Doctor Connect. It would enable you to look up your place and, according to the three criteria that I mentioned, you would get a ranking and a weighting. It is entirely possible—of course it is.

Senator MOORE: As we saw with RRMA, there was always a place that was on the border. With your proposal, would there also be those places that are just on the border of being able to be defined in the way they want to be defined?

Mr Gregory : I am sure there would theoretically still be border issues but not so much, because we are talking about a discrete place. The border issues would relate to Gundagai's shire bordering on—

Senator MOORE: I am not talking about a physical border. I am desperately trying to remember one that Michael Forshaw used to come to every estimates with. It was somewhere in New South Wales. This was a community that, under RRMA, just missed out. The world was going to end because this community did not fit the RRMA qualifications, and it was probably true. Under your process, because you are setting a defined area, there still could be a place that misses out?

Mr Gregory : Yes—border issues.

Mrs Hopkins : I think that the addition of the historical ability to maintain an appropriate workforce helps to rationalise that. It helps people's understanding because it means that there is a little bit of flexibility built into it so that you can make a case for a changing situation and a little stability built into it so that it does not change the day you appoint somebody. We think there are some possibilities to make it all seem more rational to those who are at borders.

CHAIR: What you are saying is that you would build into the criteria something that has a bit more flexibility to deal with the outliers? Is that what I understand you to be saying? If you have a border issue, you could look at that particular criterion and say, 'When you look at it in this light, there is actually an issue here and it should in fact be in that classification'? Is that what you are saying?

Mr Gregory : As your Senate colleague said, there are always going to be border issues. Let's say you have Dubbo there and you draw some lines—whether that is Dubbo City or Dubbo shire; I have no idea—but outside that will be some other shire and the definition of need for that other place will be done according to its ASGC, its population size and its history, and the definition of need in Dubbo will be done according to those three criteria for Dubbo. On the boundary between those two places you have somebody on this side and somebody on that side. Border issues will necessarily relate to any geographic system such as this.

Senator MOORE: There has to be flexibility. Now it is: you are either in or out.

Senator NASH: There should be some sort of process of appeal for border issues.

CHAIR: Yes. Then you would have a degree of flexibility and you could say, 'We could reassess this particular situation.'

Mr Gregory : But we believe there should not be as much flexibility as there currently is in the area of need scheme, whereby it can be done, as we understand it, by a state minister at four o'clock in the afternoon to make a particular place an area of need.

Senator MOORE: Or something could change, Mr Gregory! I mean, we heard in the previous evidence that a definition for a region could change with one person no longer being available—that if you have it based on the numbers of appropriate people being in a place, if you have someone who has the skills not being there, it could change overnight in terms of people who could go there. That is because we are working on such a very tight area.

Mr Gregory : I think it is worth highlighting what Helen said. If you have a place which is in need and therefore has incentives, and somebody goes, you have this dynamic issue about whether this place is still deemed to be in need.

Senator MOORE: That is right. If someone who is married turns up, there suddenly two people in the area. In terms of incentives, you have looked at a lot of them. Do you have anything that you think would be an appropriate range of incentives to encourage people in all medical professions? What would be an effective mechanism to get people into rural areas?

Mrs Hopkins : That is our 20 points.

Mr Gregory : Yes, we have. We have gone to some lengths to talk about the various things which are responsible for successful recruitment and retention. As you know, they relate to not only remuneration, but scope of practice, family matters, education, infrastructure in the town—all these sorts of things.

Senator MOORE: Housing.

Mr Gregory : Yes. What we are suggesting is that the whole system should be what we call 'refurbished'. That is for two reasons: firstly, because we are clearly not doing it right for those places where it is particularly hard to recruit to; and, secondly, because we have a new generation of health professionals. At the moment, we are using such evidence as we have as to what it is that used to attract and retain the old cohort. We have got new people. I do not know what generation they are—gen Y or something. So we need to look again at all the workforce programs. But I think you are right in alluding to the fact that it is not just the professional things; it is the family things, the business things, connectivity with broadband—everything.

Ms Handley : It is working well somewhere though—the relationship that Monash-Churchill has with particular hospitals in South Gippsland. David Eisner is a general procedural practitioner who does caesars and a whole gamut of things. He is one of the last of those great procedural GPs. Monash approached him before he retired and said, 'We need to make sure that you're sharing your skill with our students.' So they deliberately got a scheme going down on the south coast, where the best of the procedural GPs take on fifth-year students, registrars and other people. Some of them are overseas trained but most of them are straight out of the universities—and it does work well. He put in for a grant—I do not know whether he got it; I have not been in contact with him for 12 months or so—to put in lecture theatres.

Senator MOORE: In the regional centres?

Ms Handley : No, in the actual GP clinic area, where he had three flats for the rotating students and a lecture theatre.

Senator MOORE: His proposal was to build a place like this?

Ms Handley : Yes.

Senator MOORE: I was thinking that, if he had one of those, we could go and look at it.

Ms Handley : He did put in for a grant. It is all there. I do not know where he is up to with it. It is an exceptional program and it works really well. It is a town with fewer than 2,500 people. They have a visiting neurologist, obstetrician and gynaecologist. They do case managed birthing. They have caesar capability—planned and unplanned, low risk—and myriad other things. They have 10 part-time GPs—because they all have such fabulous lives—

Senator MOORE: On the Gippsland coast.

Ms Handley : Yes.

Senator MOORE: Ms Handley, have you got any information you send us, or can you send us a link?

Ms Handley : Sure.

Senator MOORE: I do not think we have seen any submission that picks that up. One of the things we found in our Queensland evidence was that kind of idea—that you would have someone with the skills who would then work with people in the region. They talked about accommodation. They also talked about appropriate training facilities—because many of the surgeries did not have that. This seems to pick up on that. If you have got a link we could have, that would be fabulous.

Ms Handley : Sure. I think that probably he would give me the whole document.

CHAIR: That would be great. If you could send that through, that would be good.

Mr Gregory : I want to commend to you our 20-point plan, because we have done some special work on this. In presenting evidence to you today, because you are meeting directly with several member bodies in the alliance you know much better and more detail—as you have just seen from RDAA—we thought the alliance's proper role for you today was to be strategic and talk about the things like research, which maybe our individual member bodies would not want to. But then we realised in doing that we were missing the opportunity to synthesise everything we do. I say again, this is our absolutely central core business for the alliance: your terms of reference. We have put considerable effort since four o'clock this morning into producing a brand new set of 20 recommendations. So we have tried to sum up all of the positions the alliance has based on the views of 33 national organisations. We have tried synthesise them in such a way as they are specific enough to be someone's responsibility. They are not high-cost, but we are quite sure that if you were to recommend even half of these 20 and half of that half were to be picked up, there would be significant progress made. I read 20 statements very, very quickly, but I would commend those 20 to your committee. Thank you.

Senator MOORE: Shame we have not put cost input in this committee. Four o'clock tomorrow morning, okay?

Mrs Hopkins : It is what departments are for.

CHAIR: Yes. We know to ask the department that. Thank you very much. Your oral evidence, your written evidence and your supplementary submission are very valuable and the 20 points will be very useful for us. Thank you very much.

Mr Gregory : Thanks so much.

CHAIR: We will suspend and restart the hearing at 1:30, but do not forget we have a private meeting at 1:15.