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Senate Select Committee on Health

MURPHY, Associate Professor Bradley, Chair, National Faculty of Aboriginal and Torres Strait Islander Health, Royal Australian College of General Practitioners

SENIOR, Dr Timothy, Medical Adviser, National Faculty of Aboriginal and Torres Strait Islander Health, Royal Australian College of General Practitioners


Evidence from Professor Murphy was taken via teleconference—

CHAIR: Welcome. We appreciate you both joining us and your participation in this inquiry. Could I ask one of you to make an opening statement, after which the committee will ask questions.

Prof. Murphy : I am sorry I could not be with you in person today. Sadly, one of the issues that faces us is that we need doctors on the ground, and I am with my patients in Bundaberg. I would like to start by acknowledging the traditional owners of the land, the elders past and present, and the future generations for whom we are hoping to create a sustainable legacy through all of the efforts that you are helping with us today. I would like to acknowledge the Ngunnawal people and the land on which you are gathered and our local Aboriginal people in the Bundaberg area. Thank you very much for the opportunity to present today.

The Royal Australian College of General Practitioners represents about 30,000 GPs across Australia, of which 5,000 have joined the National Faculty of Aboriginal and Torres Strait Islander Health. The faculty works with Aboriginal and Torres Strait Islander communities and organisations, including NACCHO and AIDA, to improve the care that GPs offer to Aboriginal and Torres Strait Islander people and advocates for policy to make this more effective. The college is a member of the Closing the Gap campaign and has signed up to both RECOGNISE and 'Racism: it stops with me,' as the poor health seen in many Aboriginal and Torres Strait Islander People is a direct result of over 200 years of dispossession and racism. Last year, we finalised our reconciliation action plan and we have signed a memorandum of understanding with NACCHO. We have heard this week the latest disappointing outcomes of the Prime Minister's Closing the gap report. While I will not repeat these figures today, I will just observe that, for me and many other Aboriginal and Torres Strait Islander people across Australia, these are not statistics; these are actually our family, our friends, our elders and our children, and I am a proud man from the Kamilaroi people of north-west New South Wales.

There is good evidence about what needs to be done to improve the health of Aboriginal and Torres Strait Islander people and good evidence that it is achievable. The first thing is foundational and everything else rests on this. There must be proper long-term respectful and trusting partnerships with Aboriginal and Torres Strait Islander people. Local people must be empowered and be given the resources and support in developing a capacity to solve their own problems. The evidence on all successful interventions shows that this is necessary. Many well-intentioned interventions have failed because they have not managed to work in partnership—knock-down approaches do not work. The second action that must be taken is that the solution must be centred on primary health care. By this I mean community based, person centred and based on long-term relationships. Only this sort of generalist care adequately manages the combination of medical conditions, mental health problems and preventative health that we see in Aboriginal and Torres Strait Islander communities. The local and international evidence is clear that investment in primary health is both an efficient use of funds and very effective. Recent research in the Northern Territory shows that $248 spent in primary health care in the management of diabetes and renal disease will save up to $2,915 in hospital care.

The Aboriginal community controlled health services show what can be achieved by providing holistic culturally appropriate care in a service that is owned and run by the community. They demonstrate that a high quality of care, in a population we tell ourselves is difficult to reach, is achievable. They also provide employment opportunities, with over half the staff being Aboriginal and Torres Strait Islander people. This is done in the midst of uncertain future funding and workforce shortages, with only about 540 doctors saying in the medical workforce survey that they worked mainly in Aboriginal and Torres Strait Islander health. Imagine what they could achieve with proper funding for infrastructure, programs, workforce and training. The success of the ACCHO sector shows what is possible. Aboriginal and Torres Strait Islander people should be able to access any part of the health system they choose, confident that they will be treated well in all senses of that phrase. While there are many examples of GP practices across the country working well with their Aboriginal and Torres Strait Islander patients, this is despite the current system rather than because of it. The proposed co-payment policy, even just the freezing of Medicare rebates, will make it harder and harder for practices to continue to bulk-bill their Aboriginal and Torres Strait Islander patients. At the same time it takes money out of ACCHOs. When 26 per cent, in the last national Aboriginal and Torres Strait Islander health survey, said they struggle to access health care, putting further barriers in the way will not help to close the gap.

Consultations with Aboriginal and Torres Strait Islander patients are often more complex, dealing with more issues in each consultation, requiring more time and needing a wider range of health professionals. Currently, Medicare does not support this level of care well—for example, one practice, which is set up as a clinic specifically for the Aboriginal and Torres Strait Islander community in consultation with their elders, generated 75 per cent of Medicare revenue, as opposed to the rest of the clinic. That is not just a matter of doctors' income; that is less money for employing Aboriginal health workers or receptionists. Not only will the Medicare rebate freeze make this worse but it is well recognised that Aboriginal and Torres Strait Islander people access MBS less often than other Australians. This has also been the case with PBS medications. We note that the removal of or the reduction in patient co-payments for medications has been one of the most effective measures in the Closing the Gap program. Medicare Locals, through ATAPS, and the complex Care Coordination and Supplementary Services program have played a significant role in mental health provision and coordination of care across complex health systems. The future of this program, let alone the extension or improvement, is unclear with the advent of Primary Health Networks. Might I say it is my greatest concern right this minute, that while we celebrate the achievements we have made in Closing the Gap, this program—which is making significant inroads right this very minute, this day—is uncertain as of the end of this month. I have got patients I cannot continue to provide the standard of care for who are going to be in limbo as of the end of February.

Finally, it is clear that poor health is not a problem of being Aboriginal or Torres Strait Islander, and it is not a problem of genetics; it is a problem of dispossession, exclusion, poverty and racism. Action on a whole range of policies will be required to improve health. This includes policies that enable children to go to school and make them feel that they belong there; that encourage employment—and the health sector is currently the largest employer of Aboriginal and Torres Strait Islander people; that tackle racism; and that recognise Australia's first people in the Constitution. These problems are not tackled in isolation; they need genuine consultation with Aboriginal and Torres Strait Islander people and long-term commitment from politicians on all sides of politics, as well as from business and non-government sectors. And policies need to be assessed for their effect on Aboriginal and Torres Strait Islander people and their health. Much of this is contained in the national Aboriginal and Torres Strait Islander Health Plan which was developed by the Closing the Gap campaign and the Congress of Australia's First Peoples in consultation with the previous Australian government. We believe this plan now needs to be implemented.

I will close with the words of Sir Michael Marmot, an international expert on improving health inequalities, writing in the Medical Journal of Australia: 'Health is dependent on conditions that enable people to live their lives in the way they would choose to live.' I thank you for the opportunity of presenting to you and thank you for the great work you are doing.

CHAIR: Thank you very much, Professor Murphy, for that very dense presentation. A copy of what you have presented there would be very helpful for the committee.

Prof. Murphy : Thank you. We will make sure you get one.

CHAIR: That would be great. The passion in your presentation was absolutely evident. Dr Senior, is there anything you would like to add at this point?

Dr Senior : No, not at this point. That says everything that I would like to say.

Senator McLUCAS: Thank you, Professor Murphy and Dr Senior, for being with us today. The take-home that I have had today is that, yes, this is Closing the Gap week; we have had the report. The targets as reported this week are not comforting at all, particularly around the health outcomes. Professor Murphy, this morning we had congress give evidence to us and their evidence was actually very uplifting. They were saying that their health outcomes in the Northern Territory are well ahead of the targets. That is something we as a country surely have to learn from; that where you have the partnership, the empowerment and the focus on primary health—with particularly, I think, the word 'empowerment' that you talked about, Professor Murphy—we now have an actual experiment happening. And the experiment is proving that we can improve health outcomes if we invest sensibly in the sort of health model that you described in your presentation. If the Northern Territory is doing so well, what else do we have to do around the country to improve health outcomes for Aboriginal people? What is the model of delivering that care? Is it more Aboriginal and Torres Strait Islander medical services? What is the model we need to focus on?

Prof. Murphy : Would you like to answer that, Tim?

Dr Senior : You start, Brad.

Prof. Murphy : As an Aboriginal man and as an Aboriginal doctor, I totally support the Aboriginal community-controlled health sector. They do an extraordinary job. I think we should be investing, as you say, wisely. It is not necessarily about the dollars spent—although we need to make sure there is enough—but it is about making sure that those dollars are actually invested wisely in proven programs. We need to make sure we support that sector. They are in limbo at the moment, as we do not know what the level of ongoing support is going to be. My own function is within the private sector in general practice and I work in areas where there is not always an Aboriginal medical service available. We need to make sure we give Aboriginal and Torres Strait Islander people a choice about where they access their health care because it is about their engagement. I get great responses. Before I made myself available for this today, I was trying to coordinate for a man who had a heart attack and died a little over 18 months ago. He has been accessing cardiology services here in Bundaberg, without having to leave his family, through the Coordinated Care and Supplementary Services program. As of the end of the month we cannot continue to fund that program. He will now have to travel, and there is a six-month wait to get him into the public system. He will have to travel to Brisbane, five hours down the road, in order to access those reviews—which often only take five or 10 minutes. That means people get frustrated with it; they do not attend. It is also an extra expense on the public system for travel and other such things.

What we need to do is, somehow or other, engage with—and the college of GPs would love to help with this—GPs and their practice teams and find examples of where the system is working extraordinarily well. We need to get that message out there so people can then model that and make sure that they engage with their communities. It is very time-consuming. In my opening remarks, I mentioned the service is only getting 75 per cent back for providing a level of care through their elders group. I see that a lot in my own practice; it is certainly not good business to engage in Aboriginal health. You can certainly make more money—pay your bills and pay the staff—by engaging in mainstream health. We need to make sure that whatever we do, moving forward, engages in processes that help those communities, particularly those which only have a small population, and encourages them to engage. Some private practices are not engaging in the Closing the Gap initiative. They are not enrolling, which means patients do not access the PBS co-payment measure. We need to look at things like administration aids to assist the co-payment measure—to package medicine so that people find it easier to take that medicine and be compliant with those therapies, and get the optimum care out of that.

We need to celebrate the successes of the community controlled health sector and take lessons from that where we possibly can. We need to support them moving forward. We need to look at the private sector to learn to maximise efficacy—to help GPs, and to encourage and enthuse them to embrace their Aboriginal and Torres Strait Islander patients, so they can provide that care. Anecdotally, from my own experience, I have seen the effects on a daily basis—the smiles, the safety that people feel coming into my practice. That all extends from that model.

Dr Senior : I would agree wholeheartedly with that. The mainstream health system can learn an awful lot from the community controlled sector, and practices that are doing this well actually start to look a little bit more like community controlled medical services. We often call them Aboriginal medical services but they are not just medical services, and practices that do this well find themselves being imaginative in the ways that they engage the community. They have elders groups and start finding ways of putting on transport for getting to the practice. They find imaginative ways of providing clinics. I heard about practice, an award-winning practice, recently thinking about how they could set up a clinic in peoples' front gardens to make it easier for people to come. The bottom line is engagement and ceding some form of control—my clinical work is in a community controlled health service, so it is not my practice to own or run. Professor Murphy is clearly deeply engaged in his community and cedes some control to the community to say, 'Let's us make my practice be what you want to be.'

There is not going to be a single approach that works nationally for that; but good practices across the country, that is what they do. Often they do it at personal expense—they want to provide high-quality care, not just generate income. There will be lots of local solutions. The health system needs to look at the Aboriginal health sector and say, 'Gosh, that's high-quality,' not 'Gosh, they have a lot of problems,' because they actually do really well and the rest of the health system can look at the sector and say, 'What can we learn from that?' I do not think we do that consistently at the moment.

Senator McLUCAS: Professor Murphy, what is the name of the program that your cardiac patient was receiving support through, again?

Prof. Murphy : It is called the coordinated care and supplementary service program. Effectively it allows me to send my Aboriginal and Torres Strait Islander patients to private services. They cannot access procedures; you cannot go and have heart surgery, necessarily. But they can have all of the follow-up care, minor procedures like exercise stress tests and echocardiograms are taken care of. They are bulk-billed where access to Medicare is, and it depends on how the program is set up, and we met with the department the other day to discuss this. But there is an opportunity. Mainstream Australians have the opportunity to go to that appointment and claim Medicare for a certain part and then there is a gap. The CCSS money pays for the whole lot. If we were able to allow First Australian people to access their Medicare entitlement as Australians and use that funding for the gap portion only, it would also allow us to get a true representation of how the Medicare dollar is being spent for all Australian people accessing Medicare. It would also allow that dollar amount that is at the moment exponentially spread to provide greater care.

As a good example, I have got a urology patient. They need to go onto a special medicine. That medicine, under the PBS, needs to be prescribed on the first occasion by a urologist. After that time the GP can continue to write the prescription. At the moment there can be a wait of up to three years to get that appointment so that that first prescription can be written. There are significant impacts on people's lives. The CCSS money allows me to get that patient an appointment. It is usually within a month, and they are starting the road towards better health immediately. So anecdotally, from my own experience, it is extraordinarily successful. It has made so many inroads. It has run better in some areas of Australia than others. It is funded and rolled out through the Medicare Locals at the moment, and that is why it is in there with the transition to the PHN. Notwithstanding that, and not being disrespectful, the problem is that the health needs of the Aboriginal and Torres Strait Islander people accessing that service suddenly go into limbo. It may take six or eight months, even if it is funded, and there is no guarantee it is going to be re-funded. It could take many months before that program is up and running again—and it does require a lot of effort and engagement. It is not as simple as writing a referral, putting on the fax machine and off it goes. You have to coordinate and engage with various services to get them to accept that instead of the patient coming in and paying their money and walking out the door, they have to get a prior approval. It is very labour intensive and surely there are ways we can make it better. It seriously is making a huge difference, and we are about to lose it.

Dr Senior : I have used the program as well, and it also funds things like CPAP machines that do not appear on the PBS or anything, for obstructive sleep apnoea. Another patient of mine has had advocacy taking her to appointments with housing to get uncertainly housed and couch-surfing and to actually help her advocate for herself with the big bureaucracy of the housing departments. One of the problems I have with it is that the criteria for it are quite narrow. It is dependent on having certain diagnoses—heart disease and diabetes. Mental health does not come into that. Some of my patients are lucky in that they fall into those categories, and others, who have the same need, do not happen to have one of those diagnostic categories, and it is very difficult to find ways of coordinating them around the services as well.

Senator McLUCAS: Thank you both. We will raise that with the department this afternoon.

CHAIR: Senator Cameron.

Senator CAMERON: Thank you for coming along. We have had submissions to the committee that say that the $5 co-payment and the reduction—the freeze on indexation—will result in a crisis of provision. A reduction in bulk-billing and a lowering of outcomes on the health of rural and regional Australians. Is that the same for Indigenous Australians?

Prof. Murphy : Would you like to go first, Tim?

Dr Senior : It certainly is, and for the following reasons. One is that most Aboriginal community controlled health services I know and other non-community controlled medical services have said that they would waive the co-payment if it was implemented. So they will take that freeze in the Medicare rebates with no way of passing it on to patients, which is actually a significant funding cut for Aboriginal medical services. It may be claimed that many of the patients will be on healthcare cards or pension cards. Just at my own service where I work I did a quick hunt through the database about a third of patients are on healthcare cards or pension cards. So there is a significant funding cut to services.

I think we have heard from other submissions about how rural and remote areas will be affected. I think urban low socioeconomic areas will also be affected. GPs serving that population not only will have a population who are unable to afford to pay a co-payment but also, if they continuing bulk billing, will suffer frozen rebates throughout, and it just makes general practice in low socioeconomic areas unviable. At the moment, the Australian Bureau of Statistics reports that 11 per cent of GPs work in the lowest socioeconomic areas and 24 or 26 per cent work in the highest socioeconomic areas. You will see that difference get bigger just because it will be impossible to have a viable practice in areas where your patients cannot afford it and bulk billing does not sustain your business.

CHAIR: You have just put a very important piece of evidence on the record because we have been focused on the rural and remote context for Aboriginal people, but Aboriginal people are predominantly located in those socioeconomic areas that you are talking about, particularly in the western part of Sydney.

Dr Senior : Absolutely, and you will note that the highest area of rate of bulk billing is in the western suburbs of Sydney around Mount Druitt. It is about 98.9 per cent bulk billing in practices in those areas.

CHAIR: Prior to the arrival of Medicare there was a great access divide between the east and the north of Sydney and the west of Sydney. Basically, people in Western Sydney did not have a GP to go to. It was very difficult for them to access. Are we at risk right now, with the government's policies of re-creating that social divide in terms of who can see a doctor and who cannot?

Dr Senior : I believe so, yes.

Senator CAMERON: One of the propositions put by the department in their submission to the inquiry is that there is no evidence that delaying access to medicine through imposing a co-payment will have negative outcomes. Do you accept that proposition?

Dr Senior : Do you want to take that, Brad?

Prof. Murphy : From my point of view, I am not into research. I can speak anecdotally from the patients I see each and every day, and I would certainly countenance that suggestion. I have people who often cannot afford to put food on the table for all sorts of reasons and have to compromise buying medicines. It affects their effective treatment. It puts them at risk of infections and of exacerbations of their emphysema states, and they develop significant infections and ultimately end up in hospitalisation. Sometimes we can cost shift and save money with silo mentality. But the health dollar, wherever it comes from—ultimately from the taxpayer—will suffer if we continue down this path, I believe.

Senator CAMERON: So the coalface evidence, if I can put it that way, is that if you impose a co-payment, it will create delays for some Indigenous Australians accessing health care. That will be bad for their health and be an increased cost on the health system in the long term. Is that right?

Prof. Murphy : If we use the figures that we had in my opening comments, where $248 invested saves almost $3,000, I think that would be the substance of my argument with this. I have patients who come on a fairly regular basis for monitoring of their mental health needs and to make sure they are taking their medication to keep their diabetes under control. As to the cost to the Medicare dollar for that regular attendance in my practice, what I saved with one particular mental health patient, who spent six months the year before last in a mental health institution, would blow the budget. Regular attendance and care—not just by me but by the practice team—saves money. When people get to know a general practice and feel that it is a safe place to go—that it is a place that they can go and not be judged and they can engage in their ongoing health care—we can actually stop treating sick people and start keeping them healthy. That is the risk that we run: if my patients and the patients that we have as general practitioners across Australia cannot come here because they cannot afford a co-payment, even as little as $5, and they do not come, we will end up treating them in crisis instead of keeping them well.

Senator CAMERON: In your opening submission, you indicated that there was a complex range of issues to be dealt with. One of the budget decisions was to remove $500 million from essential services for Indigenous communities around the country. Do you see any implications in that funding cut for health?

Dr Senior : Do you want to answer that, Brad, or shall I?

Prof. Murphy : Do you want to go first then?

Dr Senior : Yes. In the service I work with, I work very closely with Aboriginal health workers and Aboriginal outreach workers, both in the community controlled service that I work in and in the Medicare Local. They are all very worried about their jobs. Programs are being cut. So, for example, we used to have a smoking cessation worker. One of the most useful things that can happen in terms of their health is stopping people smoking. We do not have that worker anymore. There was a specific program for tackling Indigenous smoking, and, while there is still some funding, that funding was cut, and that has had implications around the country.

I do not see that anyone is arguing that Aboriginal services are overfunded. They do extraordinarily well on the budgets that they have, and they have learned to manage them very effectively in places of excess need with less access to MBS and PBS historically. My view would be that cutting the funding will have an impact on health, as will cutting the funding for broader services. For example, I have some patients who have recently been unhoused and are searching for housing. They are a couple with chronic diseases between them. It is impossible for them to manage their diabetes or autoimmune condition while they are unhoused, because it just creates too much stress. And you need fridges for insulin and good cooking facilities to cook food. So there are things like that, and feeling unsafe at home because of domestic violence—those are crucial issues that impact on health.

Prof. Murphy : Because we have two general ways of Aboriginal and Torres Strait Islander people accessing health care through the community controlled practices and through private practice, I would allude to the fact that, in private practice, with the exception of a little bit of money around incentives to nurses and the like, the income for private practice is essentially only generated from Medicare billings by the GP. So, for any GP who wants to get creative and look at options for engaging the community, you have to move away from simply seeing the next patient—and there is no shortage of patients to see in the community. If you move away from that, you actually then start spending your bottom line trying to deliver services which you could just as easily deliver to someone else in the mainstream. So it does require some consideration in that respect. And I access those services, as do my colleagues, in mainstream services that are often provided, currently, through Medicare Locals and, presumably, moving forward, will be provided through the PHN.

Can I also say that, for the first time in my life, I can proudly say that, as an Aboriginal man, the investment that I make as an Aboriginal doctor in our people also benefits the health care of all Australians.

By way of example, if we put good resources around smoking cessation, for argument's sake, to people we are engaging with, particularly people who see a wide range of people, not just a particular sector of the community, and if I use those skills and really welcome Aboriginal people and I get the successes that we anticipate and we hope for, I cannot help but use those skills and resources for all of my patients. While we are trying to catch up and close the gap, it is really important that we recognise that we are not actually talking about static lines here. If we do this really well, hopefully we will move forward and advancement the health care of Aboriginal and Torres Strait Islander people, but we also influencing the health outcomes for all Australians. That is something I am very proud about. That $500 million is not just influencing Aboriginal and Torres Strait Islander people; it is having a positive effect on all Australians.

Senator CAMERON: Thank you.

CHAIR: In the little time we have remaining, I will ask two questions. One alludes to much of the commentary you have made about the connection across boundaries and learnings from different communities. One of the things we have been hearing about regards the sharing of not just information but funding in a different way between payment for service and population or outcome based incentives for good health practices—blended models, if you will, in shorthand. I am very interested to hear, particularly with regard to Aboriginal and Torres Strait Islander people, how you would see blended models would be advanced in ways that would help that community in particular.

Prof. Campbell : Certainly from my point of view, I do not have a problem with this. My concern is how we measure it. If we are going to measure it on outcomes for, say, HbA1c, the measure that we currently use for our diabetic patients with a certain range to gauge best outcomes, optimal patient engagement, I see a problem. As a GP I cannot control the patient. I can provide the very best of care and enthusiasm, but ultimately the patient is responsible as well for their engagement in that process. If we were to go down that road, we would need to make sure that we do not disengage people from being actively involved in that. We could disincentivise GPs from engaging in this if we were involving disadvantaged communities who might not necessarily meet those agendas. We have to be very careful about the measures that we put in place. Whatever we do to engage good GPs to provide great service, we will get the results, because that is what this system is built upon: good GPs will not let their patients go without. What happens is that government funding reduces and GPs continue to provide the service because we are bound by that ethically and morally, because that is why we are in the business to start with.

CHAIR: Moving forward, has the Royal Australian College of GPs and, in particular, your faculty given any thought to the sorts of outcomes that would be helpful for a blended model?

Dr Senior : We have contributed quite a bit to the broader college submissions as well, both submissions to this inquiry and a prebudget submission. One of the common themes that comes through is the evidence about the medical home and how the patients have a relationship with a particular service and with providers in that service, and there is evidence that it breaks down cultural barriers as well. That is where people belong and they are referred on to services appropriate. In terms of funding that sort of model, what happens in that service for quality care is not just doctors seeing patients, which at the moment is pretty much all that generates funding; you have people making phone calls to advocate on housing, you have people filling out paperwork, you might have people talking to schools, people have case conferences, and people would also be seeing Aboriginal health workers, practice nurses and podiatrists.

It is about constructing a model that says, 'This is what quality care looks like, where people feel they belong to a particular practice—whether that is a mainstream practice or a community controlled practice. How do we fund that model of patient centred care—that medical home model—rather than just generating a fee each time a patient sees a doctor, whatever that fee might be?' That medical home model is what the whole college has been working on and we have certainly contributed to that model.

CHAIR: Thank you very much for using that language. I think it is the first time in this hearing that we have heard 'medical home model' articulated. It creates a concept that ordinary Australians can certainly understand—the notion of home. In my last questions I want to go to the e-health recommendation—recommendation No. 6 in your submission. Can you explain the importance of e-health for the ATSI health practices and the community? I know that telehealth is an element of that. Could you speak to the e-health area—the positive outcomes, requirements and needs moving forward?

Prof. Murphy : It is crucial moving forward but it needs to be done in a safe way, and that has been some of the resistance, I think, that we have had against the electronic health record as it is at the moment. We can have substantial savings. With the number of times that people get three or four CT scans and multiple blood tests, if we found way to share that across the platform we would not only saving money but also patient interventions and exposure to radiation and the like. So it is absolutely crucial, particularly in Aboriginal and Torres Strait Islander populations that might be more mobile than other populations. It means that all of their health service records can be easily accessed. I recall when I was working out in Mt Isa some of the challenges dealing with STIs, sexually transmitted infections, across the boundaries, which certainly are arbitrary out there and no-one sort of puts in fences. It was really hard across jurisdictions to try to track people's movements, treatments and successes and make sure that we controlled those circumstances.

So the electronic record is absolutely imperative not just for saving money but also for optimising exponentially health care certainly from a rural and remote point of view but also across the board. I use it extensively in my practice. I cannot get you a psychiatric appointment here in Bundaberg at the moment. But I have two psychiatrists who provide telehealth services on a bulk-billed basis. People are accessing through my service addiction services, which is a service that is not available in Bundaberg at the moment. So there are some really great opportunities.

If GPs are enthused and resourced appropriately they can be creative—and that is the nature of the beast. They want to find a solution to the problem. If you give them the resources, they will help to make sure they get you the outcome. So from that point of view, suddenly, exponentially, with the increases in technology at the moment, we are seeing models that we were looking at in Alaska and the likes—driven by the winters and the isolation—now starting to roll out in rural and remote Australia. That is where the focus is. That is where the impression that the need is—but it is not just there. The urban area is equally in need of these services. We are actually now delivering those services much more easily and effectively and getting a better outcome. So, from my point of view, we need to invest in this area but make sure that we do so in a way that is sensible and safe. People need to feel safe and that their information is being protected and being used appropriately.

Dr Senior : Just to add to that, we opened with talking about how well the Northern Territory have done. I think they are an example where they do predominantly use a shared health record across different communities in the hospital setting. It may be easier in the Territory but they show what is achievable with that. The Queensland community controlled sector have been very good at using their data for quality improvement activities and measurement. I think it shows the importance of knowing what you want electronic health records and e-health to do in terms of sharing data for mobile people, in terms of quality improvement—because I think those are slightly different things—and telehealth, which is crucial in rural and remote areas but also for many patients who struggle with transport in urban areas. But, again, it is trying to achieve a different thing but also depends on the infrastructure to do it, so services have to have good IT that works reliably, with people who can operate it and an internet connection—I hesitate to mention the NBN—that is reliable and works. So there is a lot that needs to happen to ensure that that is safe and not just frustratingly slow or makes people give up within 10 minutes of trying to use it.

CHAIR: We have some significant productivity impediments to effective health delivery. We are going to take a recess now for lunch. Thank you so much for the work that you do in the community, for your advocacy and your leadership in the sector and for joining us today with your evidence. Thank you, Professor Murphy and thank you, Dr Senior.

Dr Senior : Thank you very much indeed.

Prof. Murphy : Thank you very much. It has been a privilege to be here.

Proceedings suspended from 13:16 to 13:36