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Senate Select Committee on Health
16/04/2015
Health policy, administration and expenditure

FIFIS, Mrs Libby, Director of Nursing and Midwifery, Colac Area Health

ILES, Mr Geoff, Chief Executive Officer, Colac Area Health

Committee met at 9:20

CHAIR ( Senator O'Neill ): I declare this public hearing of the Senate Select Committee on Health open. I welcome you all here today. On behalf the committee I would like to acknowledge the traditional owners of the land on which we meet and pay my respect to elders past and present. I also extend that respect to Aboriginal and Torres Strait Islander people present today. This is a public hearing and a Hansard transcript of the proceedings is being made. The hearing is also being broadcast by the Australian Parliament House website.

Senator McLucas is joining us today by phone, and other members of the committee who are not attending today are Senator Doug Cameron from Labor New South Wales, Senator Zed Seselja from the Liberal Party ACT and Senator John Williams, the Nationals New South Wales.

Before the committee starts taking evidence, I remind all witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It is unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee, and such action may be treated by the Senate as a contempt. It is also a contempt to give false or misleading evidence to a committee.

The committee generally prefers evidence to be given in public, but under the Senate's resolutions witnesses have the right to request to be heard in private session. If a witness objects to answering a question, the witness should state the ground upon which the objection is taken and the committee will determine whether it will insist on an answer having regard to the ground that is claimed. If the committee determines to insist on an answer, a witness may request that the answer be given in camera. Such a request may, of course, also be made at any other time. I invite you now to make an opening statement and the community will then go to questions.

Mr Iles : Thanks very much. There are a number of points that we would like to touch on today. They include the potential for impacts of future funding adjustments that may come from a national level. We would like to also raise the question around a redirection of funding intent at a national level—and I will touch on that more later.

The other matter we would like to highlight is the need to for us to have a stronger mental health system, particularly for rural services and smaller communities. I would like to also raise the matter of the demand for compliance and accreditation, which touches on, I think, government's intent to address the question of red tape. The last matter, if time permits, I will briefly touch on is the primary healthcare networks development.

CHAIR: Thank you. I might go to Senator McLucas seeing as we know that we have her currently on the line, and sometimes these things can be a little uncertain.

Senator McLUCAS: Mr Iles, I would be very interested in talking with you about your stronger mental health services—sorry, there is a lot of feedback on this line; I will speak without hearing myself. I am the shadow minister for mental health. You may have seen recent commentary around the leaking of the documents—firstly, the overview document from the National Mental Health Commission. I have just been advised that now the full document has been leaked. It says to me that people in the mental health community are very frustrated with this government sitting on this report for so long. But I invite you to make some commentary around what you meant by 'a stronger mental health system'. If you could touch on the interface between Partners in Recovery, the Medicare Local and transitioning to PHN, from your perspective, in that part of Victoria, that would, I think, be very useful to the committee.

Mr Iles : I could pick up the question of mental health. I have to say that it is opportune that we have had recent media exposure on the mental health question. I do not have any particular view on the matter of the report, but I would like to refer to mental health as being one of the long-term challenges for the community, particularly in Colac—Corangamite. It has been a challenge for some time.

As an overall comment, services for the seriously mentally ill can fairly be described as very good in Victoria. We do have a robust system, across the state, in terms of assisting, supporting and caring for the people who are seriously mentally ill.

The challenge we have is the high-prevalence disorders of anxiety and depression, particularly for those people who are close to or, for want of a better term, knocking on the door of being seriously mentally ill. We do not have a good process for being able to care for those people in a more structured service way. Frequently those persons suffering attend the Colac Area Health urgent care centre—most people would read that as our emergency department. Managing people who are in a highly anxious state is quite problematic, and it consumes considerable resources. The relationship between the emergency department, as most people would recognise the centre, and our community mental health team is actually really good. But it is the longer term management of those, in terms of presentations; we can have presentations in our urgent care centre for up to six, seven or eight hours. The demand on our services, whether the ambulance service, the Victorian police or mental health services, is actually quite extraordinary. What we would like to see is that the mental health system has a much more structured program to it, to allow smaller organisations such as Colac Area Health—and, in the overall context of the Victorian health system, Colac Area Health is a medium-sized organisation—to be able to support our major referral centre, not only in the initial care but also in their post-treatment, step-down, return-to-community care. That is the part that is also missing in our system.

To give you some sense of the dimension of it, in each year we would average 130 to 150 cases of presentation to our urgent care centre. Those are only the people who are designated as having a mental health behavioural challenge. It does not include all of the other anxieties that come with that. So the number is a conservative number. So what we are looking for is to pick up the challenge of mental health in a much more structured, caring way, at the preventive early intervention, the initial support, the longer term support and the return-to-community support, and to see how smaller organisations such as Colac can play a role in that. Libby may have some additional comments.

Mrs Fifis : I would just like to add that I think it is important to recognise the partnerships that we have with Barwon Health community mental health service. We work closely with them when our patients present to urgent care and require mental health support. That is really the best that we can offer them, unless they are acutely mentally unwell and obviously need admission at Barwon Health—and that is often very difficult; its beds are usually full and it is difficult to get into.

Senator McLUCAS: Do you have a Partners in Recovery program in your area?

Mrs Fifis : Not that I am aware of, no.

Senator McLUCAS: That is interesting. So your Medicare Local is not a provider of the Partners in Recovery program?

Mr Iles : Yes, it is.

Senator McLUCAS: So you do not have a strong interface with the PIR program?

Mrs Fifis : We are not aware of it.

Mr Iles : Not at the current time, no.

Senator McLUCAS: Finally, you are a launch site for the National Disability Insurance Scheme and you would be aware that some people who are chronically mentally ill will be entitled to a package of support through the NDIS. What engagement have you had with the National Disability Insurance Agency around those clients who will become eligible for a package of support?

Mr Iles : That has been a long-term conversation in the trial site. We have a very good relationship with the NDIA staff, and it is a developing relationship around how we will provide services. There is a high level of concentration around how we will make that system work. That is a developing one about how we can make the various components of the system function really well. That does include the question of Colac Area Health supporting the provision of services. We are not a dedicated provider of disability services; we do provide a range of services within the context of our structure. By that I mean we have allied health services that will support clients with a disability. I think the development of this service has a way to go. There are a lot of understandings that we need to make better, and the relationship needs to be improved. I think the decision making around how services are provided needs to be strengthened. That is the area of work that we are doing. If I could make one comment about the trial, one of the things that has always disappointed me is that the trial—I am not sure it is a trial anymore; I think it is an introduction—in a sense has penalised a number of specialist disability providers, and I do find that disappointing and I think that is to the disadvantage of families and people with a disability in the shorter term. In the longer term, it may be a different question, but in the short term I think some of those providers have struggled within an environment that has been what I would call unfair.

Senator McLUCAS: That is probably a conversation for a different committee, but I am interested that you have said that and I will pass that on to my colleague Jenny Macklin. The big shift is about moving from block grants to disability service providers to the principle of choice and control, which is a huge change—I acknowledge that—but we wanted to do that in a fairly managed process.

My final question goes to the assessment tool that the NDIA is using for people who are living with mental ill health. Are you aware of the amendments that have occurred with that assessment tool and do you have any comments about it?

Mr Iles : No, I do not have any comment because I do not have sufficient knowledge of it. I am aware of it from discussion, but I do not have sufficient detail to make any comment on that.

Senator McLUCAS: I understand the NDIA has been through a process of amending this tool to ensure that it does capture those people who are seriously mentally ill and to be able to better provide them with the right sort of care and support. I will leave it at that. Thank you very much. It has been very helpful for me.

CHAIR: Mr Iles, you indicated there were several areas that you wanted to discuss with us. Do you have written opening remarks?

Mr Iles : I do. I have opening commentary written, if that would be useful.

CHAIR: Could I ask you possibly to table them for us to refer to if we may. I will go to Senator Di Natale; I am sure he will want to pick up on some of those matters.

Senator DI NATALE: The question of the federal government's responsibilities in funding the acute hospital sector is in the news today—the AMA report card has already had a bit of an airing. Can you tell me what impact the changes that were announced in last year's budget are having already on the way you deliver services here, if they are having an impact, and how you anticipate those changes will impact on services over the next decade. We keep hearing big figures of $50 billion being taken out of the public hospital system. What does that mean for you here in Colac?

Mr Iles : The current impact is minimal, close to zero. We have not had any significant impact on our funding base or on our capacity to provide services. The question of longer term is another matter. It is fair to say that health has an insatiable appetite. I do not think we would ever be able to invest sufficient resources to cover all need and want in that area. Notwithstanding that, if there was the decision to reduce a particular funding line then the position that Colac Area Health would take is that the specific services that were funded by that funding line would need to be adjusted. Where that takes us to is an era I think of there being no sacred cows in health any more, as there have been traditionally, and that is one that I think the community would become quite uncomfortable about. Let me give you an example of that. If decisions were taken to reduce funding for maternity services, our view is that it is the maternity services that would need to be adjusted. I think we could be moving into an area that is actually quite difficult for communities, as well as boards in Victoria and providers. There has been a tendency not to take that line but have other services—softer services, for want of a bit of a term—absorb some of those adjustments. I am not talking about the current funding arrangement; I am talking historically.

Senator DI NATALE: What are some of those softer services?

Mr Iles : They include areas such as alcohol and other drugs services, for example. To be really frank, those types of services do not enjoy strong community support, so it is much easier for the community to accept a reduction in, say, alcohol and other drugs as opposed to a reduction in maternity services. I think we are moving into an era where there will be quite a deal of debate and conversation about the impact of those funding reductions when they start to impact on the foundation services of rural health, such as urgent care, maternity services, surgical services and medical services. They are the ones that are the safety net, for want of a better term, for many of our rural communities. I think we are headed for a difficult time in the future.

Senator DI NATALE: To tease that out a bit more, we hear that in Colac there was a recent experience about the debates around the urgent-care service. The community made it very clear that they did not want that service to be compromised. What you are saying is that, in the past, things like drug and alcohol services have been easier to cut because they are often hidden—most members of the community will not access those services—but we are getting to a time when it is going to be impossible to avoid cutting things like urgent care, surgery, maternal and child health and so on.

Mr Iles : I think that is the era we are moving to, with the adjustments that are coming through. Not having any debate about the merits of those adjustments one way or the other, the adjustment does need to be managed and it will need to be managed in Victoria by boards and by executive staff. That will require some really difficult decisions to be taken.

Senator DI NATALE: The other option of course is that we continue to fund hospitals in the way that we were moving towards under the previous government, which was an activity based funding model that was implemented nationally. We obviously had it in Victoria for a while. Do you have any thoughts on the changes that were announced to move away from activity based funding towards a formula that is based on population growth and indexation?

Mr Iles : That is an interesting conversation. Population based funding has real dilemmas around where an organisation such as Colac Area Health fits in the overall provision of services within the population. I think the best assessment of that is that Colac Area Health has what we call a self-sufficiency level of about 75 per cent to 80 per cent of all of the activity that happens in its community.

Senator DI NATALE: Would you explain that?

Mr Iles : I will try. What that means is that for every 100 people that receive an acute medical service, Colac Area Health would provide around 75 per cent to 80 per cent of those people. The others would be higher level services that need to be provided in places such as Barwon Health or the Royal Melbourne. When we move to a population based type debate it is difficult to accommodate those realities into population based funding. It is a more complex question than simply taking the quantum of monies and dividing it by population.

The other thing I will say is that I actually support the notion of activity based funding. I think some of that is because it is what I grew up with, in terms of case-mix, so I have an understanding of it. I also have an understanding that it is particularly challenging at times and that the challenges come not from the management of those funds but the availability to provide the service. For example, if we did not enjoy the considerable support of general practice that we have in Colac, we would be in real trouble in providing these services and receiving the funding for acute, because we just do not produce the product in order to be paid. So it does have its dilemmas, but I think there is some real merit in looking at funding by activity, provided that there was a reasonable level of surety for smaller organisations across rural Australia.

Senator DI NATALE: Have you noticed any impact on your ability to deliver some of the services, such as your urgent care services, where GPs play a big role? Have you noticed any impact on your ability to provide those services as a raft of the changes to GP funding—for example, freezing Medicare indexation? There was a debate about a co-payment; it looks like the co-payment, as it was planned, is off the table. Has that had any impact on you yet?

Mr Iles : Not at the current time. We have not seen any noticeable impact of reluctance to engage because of that matter, but we have had the impact of the changed approach to work and the changed approach to work-life balance from the younger generation of medical staff that are coming through. It is not so much the remuneration question but the quality-of-life question that is actually having the impact. For example, we operate a medical service supporting our urgent care centre, which requires a GP to be available after hours overnight. The younger general practitioners are begging the question as to whether they want to make themselves available for a relatively modest remuneration. So the question of how we structure those services has to take a different model. I do not think we can rely on the traditional approach of general practice support—24 hours a day, seven days a week—that we have enjoyed for the last couple of generations. I think that era is coming to a close. We do need to develop a different model and approach.

Senator JACINTA COLLINS: In the discussion you were having with Senator Di Natale about the proportion of services provided within the region, you mentioned a 75 per cent to 80 per cent self-sufficiency factor. Do you think there is an ideal proportion?

Mr Iles : I have been around in the industry a while, and the rule of thumb that was used some time ago was that 80 per cent is about what we could expect for an organisation the size of Colac to provide.

Senator JACINTA COLLINS: So if you were looking at smaller towns in Victoria there would be a different view about what the ideal factor would be?

Mr Iles : Yes, it would, because the service provider was likely to be quite small and probably not a provider of acute-care services such as we have. If I could take one example, it could be somewhere like Apollo Bay that does not have the same structure or services that we have in Colac. To use a self-sufficiency measure for Apollo Bay would not be sensible, because they do not have the same structure of access to those services. Apollo Bay is a multipurpose service, so they have an entirely different approach. We would be looking at organisations such as Portland, Ararat, Colac, that size of organisation. We would be expecting somewhere around that 70 to 80 per cent rule of thumb.

Senator JACINTA COLLINS: Is distance from a major centre another factor in those considerations?

Mr Iles : Yes, it is.

Senator JACINTA COLLINS: When you were talking earlier about mental health, for the higher-level services, you were referring to Barwon Health.

Mr Iles : Yes.

Senator JACINTA COLLINS: I notice your closest headspace for adolescent mental health would be in Geelong itself. That fits into what you were talking about, the 20 per cent.

Mr Iles : No, I was talking about the 20 per cent in terms of acute care rather than community based care.

Senator JACINTA COLLINS: Thank you.

CHAIR: The AMA today have put out a report. For the people who might be here and for those who might be listening to the broadcast, I would like to read a little of the record of what they are saying has happened in this last year. There is a lot of debate about the $50 billion, which was clarified as $57 billion in the June estimates hearings, and now I am seeing some figures in the papers of around $60 billion. Every time we talk about that, the Liberal and National Party members say, 'It's only over 10 years. You shouldn't be alarmed about it. It is not a problem.'

This is what the AMA said has happened recently. Professor Owler stated:

The Federal Government cut $1.8 billion—

From hospitals—

… in the 2014-15 Budget by ceasing funding guarantees under the National Health Reform Agreement.

There was a further $941 million funding reduction to the States in the Mid-Year Economic and Fiscal Outlook (MYEFO) in December.

The government also scrapped $201 million funding to the states—

… which rewarded performance in meeting waiting time targets for emergency departments and elective surgery.

The enormity of the ongoing cuts was starkly highlighted when the Treasury advised the Senate Economics Committee that Commonwealth funding for public hospitals from 2017-18 to 2024-25 would be reduced by $57 billion.

Public hospital funding will be the biggest single challenge facing State and Territory finances for the foreseeable future.

I know that Senator Di Natale has asked questions around that and you were very reassuring for the local community in saying that at the moment you have not felt the impact of those cuts. Around the country different states have made up the gap because they know the community has expectations around health.

My question goes to the scale of what is on the horizon. To me, it looks like a tsunami. It is an absolute disaster. In fact, the whole of the health system, that we know, that is underpinned by this ongoing funding, is being thrown up in the air in the most uncertain way. What is the level of concern, in communities like Colac, amongst the professionals who are paying attention? Most citizens are out there living their lives, looking after their farms, employing people, doing their jobs, studying and earning a living. They do not want to worry about these sorts of things. But there are people in the community watching. What is the nature of the conversation in Colac, amongst leaders in the community and the health sector, about what this scale of change actually means for Colac?

Mr Iles : The answer to that is one of seeking clarity and seeking information and trying to get a reasonable sense of what the impact will be. That has been particularly difficult. There is a level of anxiety there, obviously. But it is knowing the real impact of that as it flows through the states and funding mechanisms to organisations such as Colac Area Health that is the unknown. Conversations with our colleagues in the department have been around the question: can we get some sense of the real impact, the practical impact, on our service and on our funding? That has not been able to be worked through as yet. That is not to say that we have not had a sleepless night or two worrying about how we might manage these services. I think the challenge for us is to find ways in which we can provide services in a much more efficient and fluent way, and I do think that there is room within the system to do that.

One of the aspects of that is one which I did flag earlier that I would talk about, and I will chat about it now. There are considerable costs within the system that are, in my view, unproductive when it comes to service delivery. If we wish to invest the highest level of resources into service delivery then we should look to reduce those other activities and requirements that take the resource away from service delivery, and I can give an example. The example is the increased compliance costs and the increased accreditation costs that organisations such as Colac Area Health face. We have five accreditation systems. Two of those are currently at a national level and one is intended to be at a national level, yet there seems to be no energy put into making that one system. Let me give you an example of that. It is the national standards that we have in acute care. Most organisations would go with the EQuIPNational standards, which have 15 standards across the system. We also would have the requirement to meet aged care standards and we are yet to receive it but we have had advice that the disability services will require another accreditation system. So that will be three accreditation systems at a national level.

My view is that we should have one system. We are not averse to having to demonstrate that we can meet a standard. That is entirely proper. But what we do need is the effectiveness of having one suite of standards that we can meet as an organisation, not five. Let me give you an example of that. In the cycle for EQuIPNational, we have periodic review. We estimate that the last periodic review cost us $360,000 to meet that requirement. If you divide $360,000 by $1,200 a day for acute care costs, this gives you close to 300 days of service that that money could have provided. Our average length of stay on acute is 1.9 days. So we are effectively talking about 140 to 150 patients that we could have treated for that service. The other part to it is that those processes require Libby's staff—as in clinicians—to be engaged and to provide time into preparing, recording, auditing, analysing and improving, and it can be argued, I think, that we actually are providing a less safe service because Libby's clinicians are involved in administrative and other processes, not necessarily putting those hours into care.

CHAIR: One of the things that we have been hearing, Mr Iles, concerns very practical, sensible suggestions of the kind that you have made. Clearly, standards are very important. There is no point providing more services if people are going to be at risk in hospitals. We need to have a very good balance between these things. But the things that you just suggested, along with suggestions that we have received in the last couple of days about reviewing items that are on the MBS scheduled, for example—old practices that perhaps are no longer relevant or can be delivered a lot more cheaply but are still attracting the same fee as when they were first introduced, even though technology may have made them extremely cheap, by comparison, to deliver—these suggestions abound. But what we have seen with the government's announcement of a cut of $57 billion is an arbitrary number cut with no policy work that preceded it and no consultation with the sector. That leads to the problem that you spoke about in the very first part of your answer to me, which is of the uncertain impact of all these things and of not being able to get information from the Department of Health. We have had similar problems ourselves in trying to get information from the Department of Health in terms of any modelling that was done around this. It seems, increasingly, that this is a decision that was made by accountants without fair and careful consultation with either the community, who prior to the election thought there would be no cuts to health, or the health experts across the nation in every field and in every area. Is that a fair characterisation: 'Cuts first; let's see what we lose on the way through,' rather than consultation, policymaking and careful adjustment of the numbers?

Mr Iles : I think is fair to say that, when we avoid making decisions as a society, if we tend to avoid challenges and hope they go away, there is a certain way of capturing the imagination and attention, and that is to talk about what it means, and for us it means a substantial, billions-of-dollars reduction in funding. That certainly captures people's attention and puts people's energies into how we might manage that. I do have a degree of empathy for those who are managing the national purse. I have a large sense of empathy for our state Department of Health and Human Services, who are juggling a very difficult set of circumstances here, in somewhat uncertain times. I am not defending the approach. I think it could have been handled better, but I do know that sometimes you have to have a catalyst, and a good catalyst is to demonstrate the consequences of not doing these things.

One comment I will make, though, is that I think part of our challenge is the nature of Commonwealth transactional arrangements. To generalise close to the point of being unfair—but I will generalise—the national or Commonwealth approach is of a transactional nature: it pays for particular services that are provided. The approach that I think ought to be built into that model is one of prevention and early intervention. I think there is much more room for us as a society to address the future demands and challenges by looking at how we actually prevent the emergence of particular conditions through prevention and early intervention.

CHAIR: The organisation model here in Victoria, I understand, is quite different from that in New South Wales, where I come from, and in many other states. I notice in the materials from your website that you have a lot more integrated care established already. We heard earlier this week from New Zealand about models of integrated care; population-based payments that become a part of that; and primary and tertiary—or secondary, I think they were calling it, but I tend to call it tertiary—integration, with nurses moving more fluidly from the acute-care setting in which they are very dominant into the primary care setting to do the preventative work and the long, ongoing management of chronic disease. So you are quite advanced in some ways, having established these local relationships.

Mr Iles : Yes.

CHAIR: How do you see the model that you have here in Victoria being implemented or received by colleagues from other states? I am sure you attend national meetings. We are hearing more and more that doctors and nurses and health professionals who straddle the acute-care and primary healthcare settings realise that we cannot continue to have just a fee-for-service model with our doctors and we need to shift to health-outcome based funding in some shape or form for the system to work. I would like your thoughts on the comparison with other states, and the ease or difficulty of the connection between the two care sectors in the Victorian experience.

Mr Iles : The model we have in Colac is not common across rural Victoria, in that we provide a substantial amount of what we call community services. They include services related to alcohol and other drugs; Child FIRST, which is the preventative gateway to child protection through family and community counselling and support; the Colac Neighbourhood House; an adult day activity service—

CHAIR: You even link into the local legal services as well, don't you?

Mr Iles : We did in the past, but in recent times we have not had quite so much interaction with the legal service from Warrnambool—

CHAIR: Is that because they have lost funding too?

Mr Iles : To be honest, I am not sure what the driver for that was. We have a model that is actually quite different. The strength of that model is that it is a wraparound service for individuals and, importantly, for families. A person coming into Colac Area Health does not come into a particular service. The ability to connect services with that model is immeasurable. I do not think we can measure the effectiveness of that in a fair way, to be quite honest. It is exceptionally effective. Let me give you an example of it. Libby's team in maternity may have a mum who is vulnerable; she and her bub may be in jeopardy of one kind or another. We have what we call a vulnerable families and babies program, which connects Libby's team with a community-services team and provides a wraparound service for that family.

Not all organisations of our size in rural Victoria have that ability, but it is certainly a model that we promote; it is certainly a model that we know works and is very effective. I think it is a model that ought to be looked at at national level, particularly in terms of shifting from a transactional nature to a preventative, early-intervention and supportive nature. That is not generally the approach of the Commonwealth, but it is one that I would really encourage some examination of, because I can see the social benefit and the social worth of that. We are also very fortunate in the structure of our general practice in Colac. We have a very good and very dedicated general practice workforce. The model we have fits well with general practice and with other private services such as psychological and support services or, indeed, private allied health and our community pharmacy structure.

CHAIR: Mr Iles, perhaps you can take this on notice. Does your model of interactive and interconnected care actually result in fewer admissions to emergency departments? We have heard about four or five key measures from New Zealand. One was a decline in attendance at emergency departments and very significant savings found in the Canterbury district by changing their model. It is amazing that, when people see a doctor when they need to or when they see a nurse over a protracted period to deal with chronic illnesses, they do not end up presenting at the expensive end of the acute hospital setting.

Mr Iles : I will take that on notice.

Senator DI NATALE: Mr Iles, you wanted to say a few things about Primary Health Networks. What in particular did you want to get on the record?

Mr Iles : The comment I wanted to make is that the Medicare Locals structure we had with Barwon Medicare Local was an exceptionally productive relationship for us. We had a chief executive and staff in the Barwon Medicare Local who were proactive and forged a very good relationship with providers in Colac—not necessarily just Colac Health, but with general practice and other services. I can see the development of the Primary Health Network as being a positive development and a positive structure for us. I am looking forward to being able to work with—I am not sure of the name of it, to be quite honest—the Western Primary Healthcare Network, for want of a better term. The empowerment of that, which probably has not been picked up in some conversations, is that geographic structure, which is basically Barwon, south-western and Grampians region, fits with the administrative structure under the health and human services departments. Importantly it also picks up the trend for more and wider geographic engagement. A good example of that is the Western Alliance Academic Research Centre that has been recently formed. It has the same structure.

Senator DI NATALE: The same geographic coverage?

Mr Iles : Yes, that is right. There are other developments of a geographic nature that it fits. I can see some really positive outcomes, and I am looking forward to that.

Senator DI NATALE: Good. I am pleased to hear that, because we have heard commentary going in the other direction. In some states they are huge.

Mr Iles : Yes.

Senator DI NATALE: It is good to see. I agree. If you can get the Medicare Locals structure and the state structure that is responsible for health working together, then there is obviously great potential. I am done, thank you, Chair.

CHAIR: Thank you very much for coming today and for your work in the local community. It is great to have champions who can come and participate in the civic processes and put on the record the things that you are doing, the successes you have and also the challenges that you face in the current climate.

Mr Iles : Thank you for the opportunity.

CHAIR: Pleasure.