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Senate Select Committee on Health

AH CHEE, Ms Donna, Chief Executive Officer, Central Australian Aboriginal Congress

BOFFA, Dr John, Chief Medical Officer, Public Health, Central Australian Aboriginal Congress


CHAIR: Welcome. Thank you very much for joining us today. I invite you to make an opening statement.

Ms Ah Chee : I would like to begin by acknowledging the Ngunawal-Ngambri people, on whose land we are meeting, and their elders past and present. I would further like to thank the committee for the opportunity for the congress to present to this important inquiry. In my opening statement, I will summarise the key points of our submission.

Amongst Australian jurisdictions, only the Northern Territory has, at times, been on track to meet the target of closing the gap in the mortality rate between Aboriginal people and the general population by 2031. This relative success can be primarily attributed to increased primary healthcare funding from the mid-1990s, directed through a network of Aboriginal community controlled health services and supported by sustained collaborative needs based planning structures; increased investment in public hospitals from the early 2000s; and supply reduction measures to tackle petrol sniffing and alcohol abuse.

As you are probably aware, the Aboriginal and Torres Strait Islander people are more frequent users of hospital care and more reliant on public hospital services compared to other Australians. Reduction in hospital funding will disproportionately affect Aboriginal and Torres Strait Islander people and can be expected to slow, stall or even reverse progress in closing the gap in the health status. Instead, increased attention and resources are needed to address continuing barriers to appropriate quality care for Aboriginal people within hospitals. Primary health care is an essential cost-effective measure for ensuring healthy populations.

However, cost is a barrier to access, particularly for the poorer, sicker populations, and Aboriginal and Torres Strait Islander people already report cost as being an important barrier to accessing health care and medicines. Any increase in point-of-care costs—for example, through the introduction of the co-payments for GP services or an increase in co-payments for prescription medicines—can be expected to disproportionately affect Aboriginal and Torres Strait Islander people, reducing their access to care and widening the gap in health outcomes. Reduced access to primary health care can also be expected to generate increased cost in hospital care needed to treat undiagnosed or unmanaged chronic disease.

Although the health system itself is vitally important, between one-third and one-half of the gap in health is estimated to be due to the social determinants of health such as poverty, poor education, poor housing, lack of nutrition, lack of meaningful employment and racism. Poverty and inequality of income are strongly correlated with poor health and addressing them is central to improving Aboriginal and Torres Strait Islander health. There are also ways in which the health system can help to address the key social determinants of health, especially through the community controlled health services. Well-designed, sustained early childhood development programs have been shown to be highly cost-effective in addressing intergenerational effects on the social determinants of health. Government can also support attempts to prevent ill health through the adoption of healthy public policy measures, particularly in relation to alcohol and tobacco use and poor nutrition.

A well-resourced and robust comprehensive primary healthcare system is a critically important platform from which to address the health of Aboriginal and Torres Strait Islander Australians. The evidence points to Aboriginal community controlled health services as a highly effective model for addressing Aboriginal and Torres Strait Islander health, particularly given the fact that Aboriginal and Torres Strait Islander people show a clear preference for the use of Aboriginal committee controlled health services and their holistic, comprehensive approach to primary health care that focuses on cultural security and public health and advocacy roles.

Aboriginal community controlled health services provide an important foundation for evidence based action, and services and programs on issues such as: alcohol, tobacco and other drugs; early childhood development; family support; aged and disability services; and mental health and social and emotional wellbeing. Multidisciplinary comprehensive primary healthcare services, such as the well-resourced Aboriginal community controlled health services operating within a secure five-year funding block, are essential for better service integration and improved patient care and, thus, for a more efficient and effective health system.

The introduction of e-health measures in the Northern Territory has also improved service integration between different primary healthcare providers and between primary health care and hospitals. However, a sole focus on competitive tendering for the provision of services leads to fragmented services with poor integration, complex patient journeys and poorly coordinated patient care. Coordinated effort is needed to support substantial increases in the number and proportion of Aboriginal and Torres Strait Islander people working in the health system, whatever the level—primary health care, hospitals or elsewhere—or role, whether it is clinical, management, administration or policymaking. Collaborative, well-resourced and sustainable processes for needs based health-system planning that include the Aboriginal community controlled health sector are critical for ensuring that investment in the health system is not wasted through fragmentation, a lack of commitment to the evidence base or a lack of understanding of the needs of Aboriginal and Torres Strait Islander communities.

In addition, the health system needs to ensure that qualified, professional and appropriate staff are available to address the specific health and wellbeing needs of Aboriginal and Torres Strait Islander people. As an alternative to the introduction of increased point-of-care costs for patients and cuts to the health system, governments should commit to the introduction of a more highly progressive taxation system that would see the well-off pay proportionately more of their income in tax than those on lower incomes. Actions to address these issues are provided for your consideration in the 15 recommendations provided in our submission. Thank you.

CHAIR: Thank you very much, Dr Boffa and Ms Ah Chee, for the journey you have undertaken, both metaphorically and physically, to be with us today. I would really like to go to your recommendations. I note that you have put forward quite a significant number at 15 and they are very strong. You indicate they are not in any particular order; in fact, they line up with our terms of reference. Can I ask you—I will come back to you—to identify, if you can, the key ones you really want to speak to on the record today; and, in the meantime, I will go to Senator Cameron for some questions.

Senator CAMERON: I also welcome you here and thank you for the effort you have made, both in your submission and in getting here. I note that one of your recommendations is a bit different from some of the other recommendations we have had. You are arguing for more funding for public hospitals. The bulk of the submissions we have had ask for increased funding for primary care and education to stop people getting sick. These are the two areas which are fundamentally coming through. I understand why you have argued that point here but, given that public hospitals are the most expensive way of dealing with health, how do you deal with the argument from some in this country that the health budget is unsustainable?

Ms Ah Chee : Firstly, from our experience and the evidence in the Northern Territory, what we have seen is the result of us being the only jurisdiction on target to meet the gap by 2031 in life expectancies because of the investment in the public health system. In fact, in Alice Springs we are seeing a trebling of the budget for the Alice Springs Hospital and we have also seen an increase in the primary healthcare system in terms of the Aboriginal community controlled health services as well as the NT government clinics. I do not think the issue is about a crisis of funding; I think it is an issue of revenue. I think what we have got to see is, as I have said, not a cut. It is not an either/or. The evidence shows in the NT that investing in the health system actually makes a difference. This issue is really about revenue, which is why we are advocating for the taxation issue to be addressed as part of increasing the revenue that is important to public hospitals and the primary healthcare system.

Dr Boffa : If I could just add to that, I think that really central this inquiry is exposing that myth that, in the public health system in Australia, costs are spiralling out of control. They are not, and it is blatantly obvious if you look at the data. We spend 9.4 per cent of GDP on health, which is about the OECD average, and much less than the US, which is about 17 per cent of GDP. According to the Australian Institute of Health and Welfare, in 2012-13, the growth in expenditure in Australia was amongst the lowest in the OECD. In fact, the average health expenditure per person fell from around $6½ thousand per person in 2011-12 to $6,400 in per person in 2012-13. And the rate of growth in health expenditure is not even up with inflation, so it is not health expenditure that is leading the budget to go out of control.

In fact, it is primarily of crisis in taxation, not a crisis in spending. So this is a myth. We are even talking about co-payments, which are a very deleterious thing to do, on the basis of that myth, and it is really important that the inquiry looks at and examines the evidence that is there about increasing costs. There are ways to save costs. There are inefficiencies. For instance, the amount of money we are spending on some of the items in the Pharmaceutical Benefits Scheme—where we are overpaying for drugs like statins—could be fixed and save $1 billion a year. There are savings that could be made. I am not suggesting that there are not, but to suggest that there is a crisis in the health system spiralling out of control is not true.

We are saying it is not either/or. You need hospitals and you need primary health care. Primary health care will help to prevent illness in the longer term and will keep people out of hospital, but right now people are sick and increasingly sick. There are 300 people now on dialysis in Alice Springs. If everyone every day were to turn up for their dialysis services, they could not meet the need. Recently people have started turning up, so they are having to turn people away. They cannot dialyse them if everyone turns up every day. There is not enough money going into dialysis. So the system works assuming that about 20 per cent of people every day will not come. But if they do all turn up, they have to say, 'Sorry; we can't dialyse you today.' So people are not even getting the care they need now. That is an extreme end of the spectrum. So we need both.

On the health improvement in the Northern Territory, as Donna just said, expenditure at Alice Springs Hospital went from $50 million to $150 million a year at the same time that the primary healthcare expenditure per person went from about $1,000 per person up towards $3,000 per person. Both of those things together made the difference and improved life expectancy, dropping mortality rates by about 30 per cent. We always said if we got the health system right we would close the gap by a third, but the other two-thirds are determinants beyond the health system. But the health system, properly structured, can help address determinants beyond the health system—and by 'properly structured' we mean community and child health services play that role. Primary medical care services do not play that role. That is not what they are there for. They are there for sick care. They do not get involved in broader issues of health development. But community and child health services do.

So we do need hospitals. Public hospitals in particular are vital to Aboriginal people. Death rates from cancer, for instance, show that access to public hospitals is not what it should be. On access to key surgical procedures, for instance, an Aboriginal man with a PSA over 100 in the public system might wait 12 months for a biopsy. That is appalling, because they have almost certainly got prostate cancer. If they can pay privately, they will get it done in two weeks. So there are huge gaps opening up in Australia now, as we speak, depending on whether you have got private health insurance or not. So there has to be a reinvestment in public hospitals, just as there has to be an investment in primary health care and prevention.

Senator CAMERON: Do you agree that in remote Indigenous communities, and even in some rural, regional and metropolitan Indigenous communities, poverty is a factor in health?

Ms Ah Chee : Absolutely. The way we see to address poverty is through education and a bottom-up approach by investment in early childhood, particularly in the early years, from nought to three. There are a couple of evidence based programs that actually assist with the sort of healthy development of kids, so that we see them on a trajectory of good health and educational outcomes. Having said that, there is also the top-down approach to ensuring that we do not have public policies that actually increase the gap between the rich and the poor.

Senator CAMERON: The budget has removed $500 million from Aboriginal and Torres Strait Islander essential services. Have you given any thought to what the impact will be on health?

Ms Ah Chee : I think any cuts in this environment, given the health status and socioeconomic positioning of Aboriginal people, are not good. Having said that, I think there is a place for reviewing where the money is spent and how it is spent. To some extent the policy framework is sometimes right. It is just how it is then executed and what sort of programs are then delivered on the ground. I do not think that overall decisions are being made based on evidence.

Dr Boffa : If I could add, a recent analysis done in the Northern Territory by Stephen Guthridge, the senior epidemiologist for the department, has suggested that almost 50 per cent of the gap is due to poverty. So poverty is absolutely the over-riding determinant of ill health amongst Aboriginal people in the Northern Territory. But not just poverty. Inequality itself is an issue. So there is absolute poverty, which is the biggest cause, but there is a social gradient in any society. So there is a double whammy here, because people are poor in a very rich country, and if you are poor in a very rich county and you are living alongside extreme wealth that in itself has serious ill health effects. So it is the double consequences of being poor in a country that is unequal and getting more and more unequal as the top one per cent get richer and richer, which government is not addressing. This is why we are here, primarily. They are trying to fix the budgetary crisis because they are not prepared to tax the top one per cent properly. So here we are talking about co-payments for the poor. In some ways it is a disgrace that we have got to this point and that we can somehow blindly not even have a public dialog about how much wealthier the top one per cent have become since the financial crisis and how they are avoiding tax—and big business. So we have a revenue crisis, absolutely, within government and we are talking about a spending crisis, which we have not got.

Senator CAMERON: Can I table an extract from Hansard of 5 February in this inquiry. Dr Boffa and Ms Ah Chee, I refer you to the middle of page 80. I am referring to the response that Mr Stuart from the department gave me and I would like your comment on it. I went through some of it while you were here. If you go to the middle of page 80 and the paragraph that starts with 'There are significant'. I was asking a question about the implication of the co-payment on both costs to the health system and to the health of individual Australians who could not access a doctor because of the co-payment. Mr Stuart said:

There are significant methodological difficulties and significant time is required to do any kind of meaningful research on the impact of co-payments, which is why most of the commentators reflect and the literature reflects on research which has in fact been done internationally and is now getting quite old and involved randomised allocation of patients to different levels of co-payment or no co-payment, in the RAND study; that research is now getting quite old. It is very difficult to do. The logistics and perhaps the ethics of randomised allocation of patients to different levels of payment within a health system is very difficult. So I think what you are asking would be a very large national or international piece of work.

After further questioning from me, he then goes on to say:

The international evidence and research is very equivocal and not directly related to the current Australian situation.

He just would not address the issue of the impact of the co-payment. He is there to represent the government in terms of that position. But can you make any sense of that type of submission from a senior public servant in the health department?

Ms Ah Chee : I will let you answer that.

Dr Boffa : I think you can make sense of it in that, unfortunately, we have got to the point where senior public servants are captured by the policy framework of the government of the day and they are not prepared to use evidence and data to inform what they are saying, even to an inquiry like this. So, sure, you can pick one study and say that is a bit old and we need to do more research, but there are many other studies that demonstrate quite clearly what co-payments will do. Professor Jane Hall, the chair of Health Economics, University of Sydney, wrote a fantastic article in The Conversation. In that article she referred a study from Germany in 2010 in the European Journal of Health Economics, which clearly showed that with a very strong methodology the introduction of a co-payment did not have any impact in deterring patient attendance at health care. So there is very good evidence in different countries in different parts of the world—quite recent studies—showing that, quite surprisingly, the co-payments do not work in terms of the original reason for introducing the price signal, which is to try to reduce use of health care. There is good evidence they do not do that.

The evidence is a bit mixed. In fact, in some studies they differentially impact on poor people. So they do not reduce the level at which people who are well-off use health services, but they do reduce the level at which poorer people use health services, which, from my own experience, I think is more likely to happen. That evidence is mixed. What is quite clear is that they either do not work, meaning they have no impact on people using health services, or they impacted substantially on poor people. There is no evidence at all to suggest they do work. So, for a bureaucrat to pretend that it is uncertain and we need to do more research is, I think, just attempting to find a way of saying what the government of the day wants to hear.

Senator CAMERON: I think you are being extremely diplomatic. I think it is one of the craziest submission I have even seen.

Ms Ah Chee : In our submission we make reference to the fact that 12 per cent of Aboriginal and Torres Strait Islander people have delayed going to a GP or did not go to one, due to costs, that 44 per cent delayed going to or did not go to a dental professional and that 35 per cent delayed filling, or did not fill, their prescriptions, due to cost.

CHAIR: Is this evidence that the health department have sought from you?

Ms Ah Chee : This is from which report, John?

Dr Boffa : It is nationally available data. I think that one is from the Australian Institute of Health and Welfare. It is in our submission. It is publicly available and should be well-known—I am not sure what Mr Stuart was, but someone like him should apprise himself of it. Australia has amongst the highest out-of-pocket costs of any health system in the world right now. About a third of the total cost of health expenditure is out-of-pocket costs, and it is already hurting people. There is really good evidence in Australia how much it is hurting people, particularly with pharmaceuticals. As Donna said, a third of Aboriginal people right now do not always fill their scripts. If people are sick and they are not taking medicines there is no way in which the Western medical system can improve life expectancy and outcomes. Adding to that is clearly going to be deleterious and it is disingenuous for a senior bureaucrat to come here and suggest otherwise, and suggest we need to do more research before we can answer the question. I can see where you are coming from. It is not what you would expect. In days gone by, in the days of people like Nugget Coombs, that never would have happened. But we have moved a long way from that. Unfortunately, senior appointments are now political appointments, and that is a problem.

Senator McLUCAS: Thank you very much for your submission and also for appearing in front of the committee today. This day has been focused on Indigenous health, particularly in the week when we received the Closing the Gap report, which is quite timely. The real take home that I have from the evidence that we had from Kidney Health Australia and from you is that, where you have Indigenous controlled health systems with a good population based public system, you get better outcomes. It is pretty simple. We heard evidence from VACCHO last year when round 1 of the co-payment was on the table. I know there have been various iterations as the government is moving its position, but VACCHO and in particular one AMS tried to work out what it would have meant to the business model for that particular Aboriginal medical service. Have you done any work on what impact it would have an Aboriginal controlled medical service in the Territory if there were a co-payment, particularly with the bulk billing incentive being removed as well? What would that mean for AMSes in the NT?

Ms Ah Chee : Not as a collective piece of work, but certainly we did some rudimentary numbers for congress on what impact that would mean for us. We would lose about $1 million out of our annual funding—well, not lose it, but we would have to subsidise that cost so we would not pass it on to our patients.

Senator McLUCAS: And the reason you would not pass it on to your patients is plainly obvious.

Ms Ah Chee : Because they cannot afford it.

Senator McLUCAS: Because they cannot afford it, and it would deter them from attending. So you would have to absorb that cost into your operational funds. So you would lose $1 million out of how much?

Ms Ah Chee : Forty million dollars annually.

Dr Boffa : To be specific, the loss of the bulk billing incentive alone for Alice Springs, which we claimed on 6,279 people in 2013-14, would be $235,000. So, when you do all the sums based on actual numbers, as Donna has just said, it would be $1 million overall, which is substantial.

Senator McLUCAS: So what does that mean? Do you cut services?

Ms Ah Chee : Yes, we would have to. We would have to prioritise.

Senator McLUCAS: Have you thought about where you might have to trim.

Ms Ah Chee : We have not gone that far, because we hope that it will not get through. If we have to then we will do that prioritising.

Senator McLUCAS: I hope we do not get there; but, usually, when these things happen, it happens in the preventive end.

Dr Boffa : To add to what you said initially: the public system is more effective at lower cost. That is the other important point. It is actually cheaper and more effective to fund the public system. For example, take an appendectomy. In the American system it costs about $17,700 based on data from the private health insurance system there. In Australia it costs less than $5,000. The administrative costs of Medicare are around six per cent. The administered costs of the private health insurance funded hospitals in Australia are around 18 per cent. So it is better outcomes at lower cost and much more efficient. You wonder what drives us to be suggesting that we should be privatising or moving to out-of-pocket costs rather than taxation funded public access to health care.

Senator McLUCAS: I agree. I cannot find a shred of evidence that says this is a good public policy approach.

Dr Boffa : It becomes an ideological issue. That is what it is.

Senator McLUCAS: That is what it is. Frankly, this is a Liberal government pulling apart Medicare as they have tried to do on many occasions, but you do not have to answer that.

Following our conversation with VACCHO, I then put to the department of health the evidence that we received from the Victorian AMS people. It was suggested that maybe that particular service was not using enough chronic disease item numbers. Would you have any comment on that? It was quite an interesting conversation; I wish I had thought of printing off the Hansard. Essentially, the official from the department said that maybe they should be using the MBS better, which sort of suggested to me that we might be pushing the envelope a little bit. How much do you use the chronic disease item numbers?

Ms Ah Chee : John can answer with the exact figures, but the fact that a number of years ago we won the 19(2) exemptions so we could get our core funding as well as bulk bill was really important in terms of investment and income into our services. So I think there is a recognition that our services can do better in terms of bulk billing and increasing that as an additional source of income, but obviously it is aligned to quality care. It is not, once again, one or the other; I think we need to maintain access to MBS, and we certainly can do better. I think that is all part of quality improvement in care as well.

Dr Boffa : I think this question gets to the issue that surrounded the policy confusion over the impact this was going to have for people with chronic disease. We had the Treasurer on Q&A say that people with chronic disease were completely exempted from the co-payment and then he had to correct himself. What it means is that, if people have stable chronic disease management and can turn up every three months and have their items claimed as care planning items, they are exempted; that is true. But, for the population we are dealing with—that is the minority people with chronic disease—there are a lot of other reasons why people need to come in in between those three-monthly care planning reviews to have good chronic care. The example we give in our submission is a patient being commenced on warfarin, which is common. You commence someone with chronic disease on warfarin and they need to come in every couple of days for awhile and then every couple of weeks. All those visits would cop the co-payment. They cannot be used as a care planning item.

But also things go wrong with people with multiple chronic illnesses. You assume you are going to see them every three months. Their blood pressure is stable, their diabetes is well controlled, everything is good. Great; see you in three months time. But lots of other things happen in that three months. People go in and out of hospital. There is some crisis. They come in with an infection and their blood pressure is up. You have to change medications. This is outside of the care planning consult. So a lot of our chronic disease patients, of which congress has more than 1,500 out of our client population of just over 7,000, have multiple chronic diseases. They are being managed on care plan, but in spite of that there is a need for quality health care to see people more often. Those in-between items attract the co-payment.

Senator McLUCAS: I could also imagine it would be rather bureaucratic trying to work out if this is a care plan visit or another infection. Do you tick a box now or—

Dr Boffa : Modern electronic patient information recall systems make that relatively easy; you can know the last time the person had the care plan review. That is quite clear. There is a recall for the next care plan review. But to turn up for planned care in that way has a level of organisation and stability required which some people have but many people do not.

Senator McLUCAS: Sure. Thanks so much; it has been very helpful for you to attend today.

CHAIR: I have a question following directly on from Senator McLucas's question about e-health. You mentioned some assistance in the red tape management, but what about the benefits of e-health and how that is impacting on the ATSI people in the Northern Territory? How is it going, how would you like to see it expanded and what outcomes from an expansion of e-health would you see as positive?

Ms Ah Chee : I think the introduction of an electronic healthcare system in the NT has been extremely important in terms of shared care. Because we have a transient population, congress sees around 3,000 visitors per year, so having the electronic system now allows our practitioners to get the relevant information about medications and conditions through the electronic health system. Prior to that there was a lot of time consumed in ringing up their home clinics to get this information. So it has become more efficient and more cost effective and there are better health outcomes.

CHAIR: Is it adequate or does it need further expansion?

Dr Boffa : My eHealth, the shared electronic health system that was built in the Northern Territory, was fantastic. It was working beautifully. The new national system that we are now implementing has lots of problems. In fact, we had a discussion yesterday at congress; we are probably going to turn it off. One of the problems is that when you have seen the client and you tick the box to upload the information onto the system in Alice it takes a few minutes but in one of our bush clinics it takes five minutes or more because of the internet connection. The access to information on that system is nowhere near as good as what we have had with the shared electronic health system in the Territory. That is only now funded to 30 June of this year, in which case that might be turned off and the only system would be the new national personal e-health record system. But that national system is nowhere near as good as what we have had.

As Donna said, what we have had has revolutionised patient care for a place like congress because we see a lot of visitors. In the old days you would try to ring up their clinic and no-one would answer the phone because they are busy—you cannot get onto Kintore. So you have a patient in front of you and you have no way of getting their list of medicines, for instance. Now, on our patient information system you hit the green button and you are into the shared record. It is instantaneous and it is uploaded into the console instantaneously. The new system is nothing near as good as that. They should have designed the new system around the system we have. They have modified the new system; it is better than it was going to be.

Ms Ah Chee : It all came down to costs again.

CHAIR: So we were saving pennies and costing pounds. Can I ask about the interface with regard to the transient population moving across borders and information-sharing across borders, because that was raised with us by Kidney Health.

Dr Boffa : No, it does not do that. Information from Alice Springs Hospital is all there. Information from any primary health care service that is part of the system is there. It can cross borders. Nganampa Health is part of the system and Ngaanyatjarra Health Service also, so it does cross borders. The trouble is that the commitment from those health services has to be there to upload the information, and some of them have not been doing that, for various reasons. So the capacity is there for the Territory system to do that, and it will be for the national system as well.

But the delay at our clinic at Utju, for instance, means that we have to wait for five minutes or longer at the end of each consult while the system uploads. In that five minutes you cannot use the computer at all. You just have to sit there, literally, and wait. People can go off and do other things, but that is an issue. The speed of the internet in remote communities needs to be addressed. Otherwise, practitioners are just going to not tick the button. They will ignore it. They will not upload the information and then it will not work.

CHAIR: So a lot of capacity building has been evidenced, but there is more work to do in that space.

Dr Boffa : Yes. The vision of broadband being rolled out is no longer there. We have to address the IT issues to make the system efficient and effective.

CHAIR: Yes. All these things are integrated. I would like to ask a question with regard to the funding issue and the funding uncertainty that we have heard from multiple providers right across the area including early childhood. I would love you to make a comment, if you could, about early childhood, as you indicated in your submission. How is the funding uncertainty that we are hearing about impacting the communities that you are looking after?

Ms Ah Chee : My understanding of the projections going forward is that, although there has been a slight reduction, there is an increase into primary health care over the next four-year period. The issue at the moment is that we have not got our funding contracts for the next financial year. But I am of the understanding that there is an attempt to have those funding contracts for more than three years. So that is a good thing. In the last two financial years they have been based on 12-month funding contracts, which is not good. My understanding is that there is a commitment by the Aboriginal health minister to get more than one year and possibly more than three years, which has been the case in the past—triennial funding.

CHAIR: What impact will agencies that are not successful have on the community?

Ms Ah Chee : There are two issues here. One is the funding that comes from the health department for Aboriginal health, and then there is the issue of PM&C and its process of competitive tendering, which, as I commented, is problematic in that it is not a process of needs based planning. Going through a process that is submission based leads to fragmented services. That is a real issue for the PM&C funding, and no decision is going to be made on that until March. One of the issues that we have been concerned about is that funding for alcohol and other drugs and mental health was transferred from Health to PM&C. We have been advocating that should be transferred back into Aboriginal health, because it is part of building a social-health team within primary health care having access to quality alcohol and other services, as well as mental health services. The whole issue of competitive tendering is problematic, and governments really do need to revisit that. Improvements in the NT have been on the basis of not just the additional investment in the health system, but the way in which we have allocated that investment. You have had the Aboriginal community controlled health sector with the Northern Territory government and the Commonwealth government sitting at the table and making decisions based on need.

CHAIR: Has there been a change in that?

Ms Ah Chee : Yes, to the extent where there is new money—particularly in PM&C—but also through the issue of Medicare Locals where commissioning actual services is an issue as well. We think that the Aboriginal specific health money that goes to Primary Health Networks in the future should come directly to Aboriginal community controlled health services, because, once again, at that level there is a process of competitive tendering.

Dr Boffa : And mainstream health. Following the Senate inquiry into mental health, which was an effective inquiry, a lot more resources went into mental health—it went into more than 30 vertical programs—but that has not funded comprehensive primary health care. You end up with multiple private providers, some of whom have come to Alice Springs and have won a tender to deliver a service in a community and they do not even know where it is. They have written a tender from somewhere else and have never set foot in an Aboriginal community and they turn up and say, 'How do I get to Epenarra?' That mental health funding could be much better spent if it was put through a planning forum and allocated according to need on a per capita and weighted basis to comprehensive primary healthcare services. There is good evidence that if you have too many providers all attempting to provide care to the one person, you get worse outcomes than having just one GP. Once you go beyond three providers—and the way money has been provided for mental health in particular—you waste a lot of money. The ATSI or Indigenous Mental Health Division have funds well allocated according to need. It is quite different, but that is not what is happening in mainstream Commonwealth health and now it is not what is happening with the PM&C process. Even big organisations like ours—we put in a fantastic submission—have done quite well out of tendering but it just leads to more inequity in the system—

CHAIR: Because little communities need littler organisations sometimes to be more effective.

Dr Boffa : We got away from that in the Territory. We allocated according to need and so small organisations did every bit as well as large organisations. It was not about how well you could write a submission or how well you could write a tender or what good referees you had; it was just about the needs of the people in that population. That is why we saw progress in the Territory. But the new money coming in and even the early childhood NPA and all of these funds have not come through a planning process. We could do so much better if we looked at the total funding pool now. If those funds were allocated in a different way, we would get much better outcomes.

Ms Ah Chee : We have done so much work in the health system in the NT in looking at the core functions of primary health care, asking, 'What does that look like in practice and what would that cost?' Then we have been developing key performance indicators so we can report against those core services. There has been a hell of a lot of work done in this space. It is just a matter of bringing it all together and continuing on that path.

CHAIR: Given the detailed work you are doing, I have to ask you this. You advocate for a large sector. What degree of consultation did you have with the former health minister prior to the budget announcement, prior to the change of policy in December and prior to the other change of policy in January? Were you consulted about the co-payment sent price signals and their impact on Indigenous people in the Northern Territory?

Ms Ah Chee : The current Indigenous health minister organised a number of teleconferences with the Aboriginal health leadership to—

CHAIR: Did any of you advocate for a price signal?

Ms Ah Chee : No. We gave a clear message that we did not support the co-payment.

CHAIR: At what time was that? Was that prior to the budget?

Dr Boffa : No, after.

CHAIR: After the budget?

Dr Boffa : After the decision was made then there was a very good attempt to engage with and talk to people about the impact of that decision and to get data to give back to government and say, 'The consensus view is that it is going to be a big problem.' The current minister did that quite well.

CHAIR: I am very pleased to hear that you are hopeful that there might be some listening happening. I thank you for coming. As I indicated earlier on, you have a large number of recommendations. If there are particular priorities that you wish you had been able to speak to today and there is more information on those you would like to send to us, please feel free to do that. I also know that we are hoping to take our inquiry to the Northern Territory in the April-May period. I hope we will be able to see things on the ground with you there.

Proceedings suspended from 11:12 to 11:22