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Senate Select Committee on Health
13/02/2015

BRIGGS, Ms Lisa, Chief Executive Officer, National Aboriginal Community Controlled Health Organisation

[14:12]

CHAIR: I welcome Ms Briggs to the table. Ms Briggs, would you like to make an opening statement?

Ms Briggs : I would. Firstly I would like to acknowledge the traditional owners of the land we are meeting on today, the Ngunawal people, and our elders past and present. And I would like to thank you for the opportunity to present publicly in addition to our submission.

NACCHO is a representative body of 150 Aboriginal community controlled health services nationally who are in service across 302 sites. We predominantly see the most at-risk and the hardest-to-reach Aboriginal and Torres Strait Islander people across the country, and equally we perform over 2.1 million—and growing—client contacts per year.

Although we have challenges—as we heard in Parliament House this week—regarding closing the gap, I would certainly emphasise that investments and changes can make things more achievable and can make things happen. It is important that we do not see change as unrealistic; it is important that we do not think, 'We are not going to make the change within a generation'. No matter what the reforms or who makes the reforms, what is important is that they continue to work with us, and that those reforms work to our benefit. It is important not to create further disadvantage for Aboriginal and Torres Strait Islander people, because these are the people who actually need these fundamental services, no matter if they live in urban or regional or remote areas of Australia.

The engagement process is critical. What we find as part of reform is that within NACCHO, particularly, we know a lot about health systems, because of the structure we are in. Therefore, if you walk with us as part of that process you will get better outcomes and you will see further outcomes by the members we serve.

CHAIR: I have a question on how you would characterise the 'walking' with you that has been going on in this period over the last 520-odd days since the change of government. We have heard from many other agencies, peak bodies for every health professional sector, that they were not advised prior to the announcement in the budget of the proposal to introduce a co-payment. They got half an hour's notice prior to the changes in December. The third version, when it emerged in January, was also at very short notice. How would you characterise the detail and timeliness of consultation with NACCHO, given your status in the Indigenous health community space?

Ms Briggs : I would agree with my colleagues who spoke to you earlier today. There was not enough in-depth conversation, particularly from a policy point of view, that was evidence based to help guide good, informed shaping policy around any changes to MBS or universal health care.

CHAIR: If evidence is not being used to shape policy, what is being used to shape policy? Is the policy being made or are the decisions being made?

Ms Briggs : There is no policy detail for us to look at. Even when the co-payment was announced as part of the platform, without the detail underneath—and we are hearing it on the run—you cannot respond. We are doing policy on the run rather than having good evidence based policy to begin with. Should that have been the area of focus? I would disagree. I think there are other ways you can have good health reform without targeting universal health care. Does that make sense?

CHAIR: Absolutely. It certainly makes sense.

Ms Briggs : I would further say that the co-payment to me and my board members whom I met with today—and you would have met our CEO from Congress in Alice Springs, Donna Ah Chee—that co-payment is only one barrier we are going to face within this policy. We need to see the broader detail around what is underpinning the MBS changes that will follow in the larger scale, not do the policy-on-the-run stuff.

What has come to light recently, is the absence of consultation with our member services, NACCHO particularly. It was way back in 2012 when they started to make changes to our Aboriginal health-worker provisions around accessing MBS item 715. It will have huge implications not only for revenue but also for quality of service and cycles of care. You are now impacting on the model, not so much the incentive. There needs to be a much more robust discussion about what that MBS change really means—not just looking at the freak coming through at the moment.

CHAIR: In your submission you said, 'To build on current progress the Australian government must renew its commitment to the programs that are working and their expanded delivery through health services that are culturally appropriate and economically effective.' Could you expand on that point?

Ms Briggs : We would argue that our Aboriginal and community controlled health services are pivotal to making any comprehensive journeys part of the system in making Aboriginal people well. We know from the model of service we provide. You were asking before about cultural awareness. You were asking before about quality of service. You were asking before about accessibility and affordability in a different way. That is what our model is about: affordability accessibility and quality.

Within our services they understand the complexities of chronic disease management. They understand the complexities of social environment and all the impacting factors so that when an Aboriginal person comes into the service they can get the appropriate care at the appropriate time and not have to wait for a GP appointment, in a rural or remote area. It is to not create further barriers.

The real barriers we see from our model, looking out, are that when you have fly-in fly-out services the continuity of care is compromised. If you cannot get on that waiting list until two or three months down the track for a specialist service or an allied health service—because of the need on the ground—it will compromise that cycle. You will have more people then fronting up at hospitals. While we see more people coming through our doors, they are able to access it at no cost. They are able to get screened through a whole system, because we know automatically that if you have diabetes you are more likely to have high blood pressure, cardiac issues, blah blah blah, and we will screen you for all of those the minute you walk through the door.

CHAIR: What are the threats your organisation faces?

Ms Briggs : I have a list here for you. More globally—you would have heard some of the more local-front stuff that was presented earlier today—we really do need additional infrastructure. There are policy changes around infrastructure, and we have been struggling to even get that to be accessible for our member services. We really need some type of priority of access or something that makes it more realistic for our services to approach that.

When we look at infrastructure costs, already we are looking at an additional $116.5 million for next year. We are not saying there needs to be new money. We are saying there needs to be a redirection of the current money so that it is targeted. We are also saying there needs to be enhanced access to remote services around program funding. We know there needs to be the investment of $189 million to make that occur. We need enhanced access to the Rural Health Outreach Fund. We know that is also under review.

All of these things will have a lot of impacts on our service delivery, particularly in rural and remote Australia. We need to have a look at the renewal of funding for clinical service delivery. We know we also need to have a look at reinvestment into our Aboriginal health services from some of the services that are not directly front-line.

Probably the greatest risk, right now, is funding uncertainty. We need to call on government to make that certainty happen. If you do not, we start haemorrhaging the workforce. We are not just talking about GPs, we are talking about nurses and allied health, because people need to live and they need sustainability, and we have three months to go. If anything needs to happen, that is No. 1.

CHAIR: Before you go onto the next thing, if funding certainty and review, generally—since this government has come in—has meant cuts, if funding certainty results in cuts to the services you are representing and talking about here, what will the impact be?

Ms Briggs : The impact on the ground overall will mean who can and cannot deliver a service to an Aboriginal and Torres Strait Islander client. What might happen is the Northern Territory—and we have provided some maps to you guys as part of evidence—might get some funds and Western Australia will get no funds. Is that right? I think not. Aboriginal people deserve the same continuous cycle of care no matter what location they are in.

If they are going to do cuts they really need to think about the impact. That front-line servicing, that access to a GP that is affordable and accessible, and that quality cycle of care—you will compromise all of that, at some point, as part of the journey. It will predominantly mean we are going backwards towards the close-gap targets. We will see more hospitalisations and more deaths, because of those front-end services not being funded appropriately and not being achieved.

CHAIR: Is that what you feel will happen?

Ms Briggs : Yes, a little bit. We need the commitment. The fees are real without the commitment, and we do not have that.

CHAIR: You went to that point in your statement: 'The current focus on the reform of Federation has implications for the health sector and administration. Progress against the Closing the Gap targets could be lost if the government seeks reform that reduces the national focus on the Closing the Gap framework and would undermine the consensus achieved not only at the federal level but with the states and territories.' You call for a whole-of-government mechanism. Given the nature of the consultation that you have had with this government to this point, do you really have any hopes of a whole-of-government, evidence-based, needs-based policy development process?

Ms Briggs : We have to have hope. But we need to stop the rhetoric and get on with the action. In the absence of a national partnership agreements or anything that underpin accountability mechanisms for Commonwealth and state and territory governments, we are going to have a losing battle. I think we need that further commitment by the Commonwealth, reinstilled in practice not just in theory, as well by the states to commit in matching terms so that the programs will continue and expand. Those discussions in more detail are yet to be had. It is a call of urgency. We really need that certainty about where we are going. We should not have to wait for the federal white paper or green paper, or whatever we call them these days, because the need is now; it is not down the track. Our people have already waited far too long for some inroads and we are making those inroads now, and we cannot afford to go backwards.

CHAIR: You are a very hopeful person because what you just asked for is for the Prime Minister to actually glue back together the national partnership agreements that he tore up on coming into power.

Ms Briggs : One of the key things I am hanging onto—and I mention this quite often—is the national Indigenous reporting agreement, which expires in 2018. It is the only accountability mechanism we have left under the targets. That is what I am keeping my eye on. We are in 2015, so we still have three years to make sure we are working to some mechanism to hold us all to account, not just state and territory governments but everybody including us.

CHAIR: Thank you very much.

Senator McLUCAS: Thank you very much for your submission and for appearing today. We will take up that question about the MBS changes to item No. 715. Can you explain what the 715 do?

Ms Briggs : I am happy to forward you our position papers on that as well.

Senator McLUCAS: That would be good, thankyou.

Ms Briggs : The 715 allows Aboriginal health workers to work with the GP around the health assessments. It also goes through to team care arrangements. So you are talking the continual cycle of care. Remove a health worker being able to do that—our front-line, engagement people; it is not the GP necessarily—and that poses risk. We really need the number for—

Senator McLUCAS: Is that particularly used by ACCHOs?

Ms Briggs : Yes, absolutely. If you are registered through the PIP through MBS, you can claim those provisions of service. It can be broader not just within the ACCHOs, but it depends on whether practices have chosen to undertake that provision.

Senator McLUCAS: Okay. We will raise that with the department later this afternoon. This is Closing the Gap week. The report on Wednesday did not give us great hope. It is slowly heading in the right direction but slowly. However, congress's evidence this morning around the achievements in the Northern Territory was somewhat heartening. Surely, there is a lot we can learn from that. Do you have any comments about the obvious success that congress is having in the Northern Territory? Can you make some comments about other ACCHOs around the place?

Ms Briggs : Yes. It was predominantly through the Institute of Health and Welfare report that we commissioned last year, specifically about our services on the achievements against the Closing the Gap targets.

What we found was our model of service was very proactive over a 10-year period in the reduction of child mortality rates by 66 per cent. We equally found—and I stand to be corrected—that over the four-year period we were able to increase life expectancy by 33 per cent. What it showed us was: where there are mums and babies programs put into services, you get better mortality outcomes—it changes the whole scope. We still have a gap in that area of 34 per cent, because we do not have enough mums and babies programs nationally to be able to service the need. We would definitely need to see an expansion of that if we want to see a generational change and meet the target by 2018. If there has been a larger investment in the Northern Territory, which Donna might have mentioned today, there might not be the same investment in Western Australia or South Australia. I picked those areas because of the maps I have provided you with. In terms of life expectancy, you can see that there needs to be a much greater investment and targeted approach around that, because we still have 67 per cent that we need to close further.

Putting in targeted needs around diabetes—which is the No. 1 thing to do around affordable hospitalisations—is a quick win, but when you do not have diabetes educators and when you do not have access to specialist endocrinologists or other service providers or even Aboriginal health workers who are skilled up in this area, you are never going to be able to meet that need in the time you would want it. That is another example of targeted approaches for change that are achievable if we do the right thing now.

Senator McLUCAS: One of the intents of the co-payment is to reduce the number of GP attendances nationally. In terms of Aboriginal health outcomes would you like to add to the comments that AIDA gave me earlier?

Ms Briggs : Around the co-payment impacts?

Senator McLUCAS: Yes.

Ms Briggs : I am happy to provide the papers on the GP co-payment, but I think I need to clarify one thing first. Most of the dollars that are coming in through the Department of Health are for GP servicing and nurses. The MBS funds that we generate as part of that provision are for things that the department does not fund—so it is an add on. I will give you an example from Geraldton: Geraldton AMS is funded for three GPs. They service 8000 clients. If you were doing the ratio of the world standard, they would need 12. The only way that they can then fund an additional doctor—they would still be short—is through MBS revenue. You start taxing or fiddling with that, and I can see a reduction. That is just an example of the impacts of co-payment. Where there is no Aboriginal health service in a cycle of care of diabetes—and this is a case study that we have done—you need nine episodes for that continual cycle every three months. That means you will be charged a charge of whatever the co-payment is every time you want to do part of that cycle. That is not affordable and that will compromise care. When you talked about impact statements before, if that is not hard-hitting enough or evidence based enough, I do not know what the impact stuff we can tell you it except that what is going to happen in the data in three years' time.

CHAIR: The costs will be crazy.

Senator McLUCAS: And the health outcomes for the population in a really short period of time, potentially.

Ms Briggs : One of the worries we had initially around the co-payment was about the things that are not chronic diseases—immunisation, for example. You do not want to compromise immunisation ever in Australia. We can see what happens in other countries when you do, so I think we need that best practice always maintained. They have missed that, where mums need to go and have particular procedures that are going to cost if you do not bulk bill. And we are running out of bulk-billing services, so that is another issue. That is now off the table, but if that starts to creep back in again, then that is going to be an issue because we are already struggling to get our mums through shared care arrangements. It is not just early years; you have to expand it to the mums first, to make sure they can get into hospitals. I am not sure if Donna mentioned today about how difficult it can be for mothers who are in remote areas to get to mainstream hospitals in major cities for birthing. It is crazy. You are going to have women from Mornington Island, as an example—there is a policy in Queensland where, because of high risk, you must leave your community in your second trimester. Imagine what it would be like for yourselves, as women on the panel, to leave your home for three months. You have to leave all your children, your lives, and you have to wait there in a hospital until your birth. There have to be better mechanisms that we can create around that because, again, putting the co-payments in is going to drive that further away. We already know there is an existing gap.

Senator McLUCAS: Very briefly, when we were doing round 1 of the proposals from the government, we had evidence from VACCHO about how that would affect their business model, how they could continue to run one of their services. Then when we went back to the department, the department said that is because they were not using the chronic disease item numbers enough. Did you want to make any comments about that?

Ms Briggs : Certainly. What the department does not understand is the model. And in absence of the model, you cannot tie MBS items to the cycle of care because you do not know how it is packaged. You can put in place all the MBS items you like, but unless you streamline them—so if they have to be just triggered by the GP, and you put all these things underneath it that make it difficult to get to the chronic disease package—no-one is going to take it up. They have not looked at the workforce shortages either. I do not see a million GPs running around with no jobs; I find that a lot of the GPs are already taken up, and largely by hospitals as well. We already have a shortage of women GPs, which I am sure colleagues would have mentioned before. I think MBS is only one little component of the actual problem, and it is the mechanisms within that they really need to look at before making changes or fiddling with the adjustments.

We have called for a larger think tank or task force of NACCHO and people within the department to look at MBS as a whole that specifically are for our people so that we can help them. This is what I mean when I say 'Walk alongside us': help them make good policy decisions so that they are more targeted, more accessible, more usable. We know the MBS is a good way to complement care. But we know where there are services that have a lot of GPs, they can action stuff where they have good machinery and that inside: you are going to be able to maximise it. Where you do not—and I would say in a lot of rural areas, the further you go out the harder it is to attract—New South Wales would be a classic example—it is going to be much more difficult for them to maximise it. So for me it is a bit of a cop-out because they are not looking at the whole picture, only one portion of it.

Senator CAMERON: Ms Briggs, could you take us through this MBS 715 and what you actually do under 715?

Ms Briggs : Can I bring that one back as part of a paper? I know I am going to make mistakes around it. Globally, I can say it is specifically for when they do the health assessment stuff and the Aboriginal health workers are part of that cycle of care where they are able then to claim it. But if you need more detail on that, then I would rather table what we have back at work so that I do not give you the wrong information.

Senator CAMERON: Okay. That is fine. The government has also cut $500 million out of essential service support in Indigenous communities. Does that have implications for health?

Ms Briggs : Absolutely. Again, from the evidence that we submitted earlier, issues around mental health, social and emotional wellbeing, and youth suicide—we can see those escalating at alarming rates. It seems—and this is me just making an assumption—that mental health is not really seen as a frontline service. I actually think it is. It is part of your core delivery mechanism. I think when you start removing funding away from that, it is going to start to show and hurt, particularly within our communities.

Also, when you start moving and mucking around with GP registrars, it then impacts on workforce deliverables and attraction into our services. When you start mucking around with infrastructure, it then actually shortens the provision of care because, under national standards in Australia, you have to be able to comply so that you can expand. I think there are fundamental things that have a domino effect that unpack underneath that in that detail.

If the preventative-arm workforces, particularly around the CTG tackling smoking—which I know is under review right now—are removed, we are never going to be able to reduce the 25 per cent target reduction rate within Aboriginal and Torres Strait Islander people. More globally across Australia, we have had a lot more investment and targeted investment that has been accessible to the wider public—but those same things have not been accessible to us. We are calling for long-term investment—that has been provided to the rest of the public—to see long-term gains for us. That way we are going to be able to achieve that. I think those prevention things are critical, rather than just trying to manage chronic disease function itself.

Senator CAMERON: You spoke earlier about evidence-based policy. The department, when it appeared—and I am sure they are there at the moment; I would assume they are, because they are up next—on Thursday, 5 February, indicated that they were unaware of any authoritative research in Australia specifically about the impact of something like Medicare co-payments or a reduction in the rebate. The question I asked was about the implications for Australians having to pay more to go to the doctor and some people not going because of the payments. They also said that the overseas evidence was equivocal. Are you equivocal about the implications of adding costs to people going to the doctor?

Ms Briggs : Absolutely. I think that what we have seen from overseas, like the US-based medicine, is not healthy for any Australian—never mind Aboriginal and Torres Strait Islander people. I think our universal health care is what sets us apart as world leaders in health, and I think we should maintain that.

Potentially what we are doing is privatising health—and that is not good. It is not good policy. It is not good for Australians. It is not good for us. Again, we have to find other reform measures where we are able to keep universal health care more broadly, rather than the smokescreens—as I call them—of GP co-payments, removal of MBS 715s and those types of things, which really impact at the core, the fundamental base, of GP clinical care.

History tells NACCHO—and I have said this before to other colleagues—that when you had barriers up before the 70s—before 1972—before our first health service in Redfern was established, our people were dying at more alarming rates. We could see, without that investment—that continued universal care investment—that come back and sneak back. If we are going down the privatisation way, it is going to block us out of the system; which was why we were established in the first place and why our work to ensure that that does not happen is so critical.

Senator CAMERON: Can you just explain to me what the implications are in relation to NACCHO and to your capacity to provide health support to Indigenous Australians because of the co-payment and the freeze on the rebate?

Ms Briggs : What NACCHO does, as part of our system and structure, is we have ourselves based here in Canberra and then we have seven other state affiliate bodies that work collectively with the 150 shared members. So the role that NACCHO can play, at a much higher level, is to work with places like the RACGP and the AMA to ensure that when we are talking about GP provision of care we are, firstly, looking at accessibility; secondly, that we are looking at affordability; and, thirdly, that we are looking at general quality. I am really trying to simplify it as part of that message because we get so caught up in the department's policy and I am trying to keep everyone focused on the fact that, for our people, those are the three underpinning things that need to be maintained at all times to ensure we live longer—to ensure we can grow up with our grandkids and watch them grow and to ensure our grandkids can live longer and so on and so on, for that generational change. I hope I am answering the question; I am trying to really underpin that any change to health reform or the health system needs stronger dialogue and debate with us about what that should look like—so again, that the government is working with us, not for us.

Senator CAMERON: Do you have funding renewal that is going to take place soon?

Ms Briggs : No.

CHAIR: Do you have funding into the future? How long is your funding?

Ms Briggs : All of our services, NACCHO included, are only funded until 30 June this year. We have been calling quite hard for a renewal of those funds and that long-term funding.

We know there have been precedents set in Prime Minister and Cabinet, under the Indigenous Advancement Strategy, where four-year contracts have been delivered. We do not really understand why we cannot see the same in health, particularly when it is already within the forward estimates. It really just needs for us to get on with business. Give us that certainty so we can keep on doing we are doing.

Senator CAMERON: Maybe the department will be able to tell us when they appear shortly.

Ms Briggs : I hope so too. I will wait and listen.

Senator CAMERON: Yes.

CHAIR: Ms Briggs, in relation to your submission: you mentioned the impact of reduced Commonwealth spending on health services broadly but you also mentioned hospitals. Could you elaborate on the impacts of the cuts to hospital funding?

Ms Briggs : From our position we would prefer there was less hospitalisation. We really agree with avoiding hospitalisations. But there are blockages for the hospitals; we know there are a lot of patients who go to emergency, but are they going right through the cycle of care for tertiary care? I would say not. I think what we need to see in reform is that change, because it is no good for our Aboriginal people to just front up to emergency without getting the outpatient and follow-up care they need through specialist services. At the moment we have access from national data we have showing 34 specialists. We already know the rates of Aboriginal people who have diabetes; if we have 150 services, we need 150 endocrinologists. If we have more people with issues around cardiac health, where are our 150 cardiologists? This stuff around hospitals is really about how we engage and make it better and more accessible for specialist services while also ensuring it is at the prevention arm and avoiding people going in to the emergency department. Whether that model means coming in to our Aboriginal health service, or fly-in fly-out, this could be a lot better. It is a big improvement that needs to be made.

CHAIR: We heard earlier today from Professor Campbell. He was speaking about the rural context, but he also started to speak about Western Sydney, where there is a very significant Aboriginal population. He said that he believed that, if the changes that are proposed by the government with regard to funding go ahead, there will be an exodus of doctor services and GP practices in Western Sydney because they simply will not be able to afford it.

We have heard about cross-subsidising that might be happening, where people in rural towns—such as our doctor from Scone was saying—will have a bit of rationalisation where those who can pay will pay a bit more and try to balance it with those who have less. In Western Sydney, with a limited capacity to do that sort of cross-subsidisation, there will be a withdrawal of GPs who will move their practices to places where they can afford to pay for the cost of their degree. I suppose this is already happening, but it looks worse into the future. For the non-rural, city-based Aboriginal community, would you like to put on the record your perspective about the threats to the health of that community in this current climate?

Ms Briggs : Yes. It was a good way that you put that, Senator, because it made me immediately think about the ambulance officers when they have to go to a different hospital and do a redirection of services. If that is the case, if our people have to travel further to get to specialist services or further to get to hospitals, is that going to happen? They are again limiting accessibility to the cycles of care as part of that process, and that is why I think we have got to do better—particularly in that area—to make sure that that does not happen.

I have family members who work in the Liverpool Hospital. I think maybe in Canberra, because they are far removed from other places, that it is only going to impact on the Western Sydney mob who live in Dharruk and so forth. But they have a lot of people who come from the Northern Territory, South Australia and rural New South Wales, so what does that mean in terms of them accessing urban hospital services if we have cuts that are based around accessing specialists or those tertiary services. I think it does have a much larger ripple effect in terms of waiting lists and cycles of care for Aboriginal people, and I can see that that will impact on closing that gap within that generational change around that life expectancy target, because you need that cycle of care to occur.

We have seen good mechanisms in Newcastle with Dr Kelvin Kong purely through ear and hearing services. He was instrumental within the New South Wales based hospital where he worked, both in the hospital itself and in the Aboriginal health service there, Awabakal. He brought the specialists out to the service. They had a four-year waiting list for ear health surgeries, and they were able to improve that mechanism to reduce that waiting list to two weeks, which is quite remarkable. But there has to be that existing spend to be able to do that. It has to have the good will within the states and hospitals to do that, and it has to have the good will from the Commonwealth to support that.

CHAIR: The white paper process is obviously of great interest to you. Given the degree of expertise that your submission and your testimony this afternoon have provided, how deeply engaged have you or your organisation been in the development of the health elements of the white paper with regard to state-federal relations?

Ms Briggs : We have not been engaged in the actual framing of what that looks like. We have been invited to initially start the consultation process about that and what it will mean. Internally, with our national leaders who sit around our board, we are trying to position ourselves and get our head around the real impacts that any federal reform will have. Again, I have to go back to my opening statement about how we are very good at health system reform, but, if you lock us out of that process without assisting those that are shaping the policy platforms, we are going to miss the mark. We cannot afford, any longer, to come after the fact because for too long we have been doing that. That is a very strong direction from my board that I have heard in the last few days.

CHAIR: Do you have a time line of when the consultation is going to happen, moving forward, and the delivery of the paper?

Ms Briggs : We are already starting to get that moving. I cannot give you the actual date, and the paper, but I am happy to forward them on.

CHAIR: Wonderful. I appreciate that, Ms Briggs. Thanks for the work that you do and for your testimony this afternoon.