Note: Where available, the PDF/Word icon below is provided to view the complete and fully formatted document
Senate Select Committee on Health
09/10/2014

HOSKING, Mr Kim Anthony, Chief Executive Officer, Country North Medicare Local

LEE, Ms Debra, Chief Executive Officer, Northern Adelaide Medicare Local

SEIBOTH, Mr Chris, Chief Executive Officer, Central Adelaide and Hills Medicare Local

[09:45]

CHAIR: Welcome. I invite you to make a brief opening statement.

Mr Hosking : My presentation will start with a couple of stories and I will use those to illustrate our story of the Country North Medicare Local. An octogenarian man undergoes surgery to remove a tumour on his bladder. He is discharged to his home that same day, an hour's drive from hospital, where he lives alone and now with a catheter and no advice on how to manage it. In pain, he is bleeding into his catheter. His friends recognise his discomfort and after a return journey he is readmitted to the hospital and spends several days with an infection. He is called back for a second operation and is discharged the same day only to be returned again and readmitted. He is asked to come back for a third operation with no explanation. He receives a letter from the hospital in the mail to advise him that he has an aggressive cancer and without surgery he will die. His family travel seven hours from another town to take him back to the hospital, whereupon it is discovered by a simple reference to his notes that the planned third operation was indeed the second operation already done and that the notes had not been properly reviewed. The second operation had cleared the cancer.

An 82-year-old lady collapsed at her home and was discharged that same day. She was unable to walk or sit and lives alone unable to care for herself. She lives within the metropolitan area but not the area defined by the state health service as metropolitan. So she is unable to access a weekend assessment of her needs and the implementation of care in the home. She must sit in a queue for help to be supplied by contract service providers. If she lived three kilometres down the road she would have been able to access a seven day a week immediate support service. Another octogenarian man residing in the Ceduna travels on his own by car the 800 kilometres to Adelaide for an outpatient appointment. Upon arrival he is told the clinic has been closed today and he is asked if he can go home and come back the next day.

A patient with an acute mental health issue presents at a country hospital in the early evening. His situation requires that he needs immediate professional mental health support 2½ hours away in Adelaide. An ambulance is called. The ambulance will not be made available for transport for eight hours. The patient waits in his distressed state in the small hospital A&E, supported by the solo town GP, who has worked all day and now must work all night and still manage the next day's work. Finally, a 13-year-old girl in a small community has realised her same-sex attraction and is acutely depressed and seeking help. The only available support is provided by an NGO provider in Adelaide that bends the rules to include a younger than usual client. The girl must travel 2½ hours to Adelaide each week to access assistance. Her access to psychiatry, referred by her supportive GP, is also in Adelaide and again she must travel. Indeed, mum or dad must surrender wages and time and cost of travel to assist.

Our country lays claims to having among the best health outcomes in the world. These anecdotes, however, describe the journey of patients within our system. Each anecdote describes an easily avoidable incident. Each describes an unnecessary cost to government and the community or impost to the individual. They are not unusual experiences. They are each avoidable. They are in the main focused on the acute and primary health interface. They are easy to access as they are clearly identifiable issues. A greater many issues are not so easily identifiable. While each reflects a story from the country, as the metropolitan areas expand and services are retracted towards the centre, the needs of the outer metropolitan areas are not dissimilar. None of the anecdotes identifies a problem that is not easily fixable and indeed at little cost. Each identifies the issue I shall simply describe as variation, where Australians who have the same health conditions, concerns or problems do not necessarily receive the same healthcare.

We have a fixation on big picture system change as the catch-all for improvement. We react to new ideas being trialled elsewhere, to solve the problems of elsewhere, and we think we can make that fit. We react to state of needs of each health discipline tribe as they profess the solution that their particular tribe can bring. We have made change a debilitating constant. The change that would be ideal is one that focuses on the patient, the consumer, of our collective health product.

The great majority of us do not think about health until it is us that needs help. Then we want to feel that the system is working for us. Health is no longer accountable to the community unless the community is defined as big government and big systems. National consumer bodies tell the tale of the little person's need, but who captures the tale of that man from Ceduna.

Health will apparently become more economically manageable through big solutions. But each of the anecdotes identifies opportunity for small solutions that can be applied in small ways and locally. National and state performance indicators are set but seldom measured accurately. They miss the right questions to supply the right answers. Cost of health is measured in the GDP cost to government, not the GDP cost to all. Real savings and real improvement is available to us through greater transparency of local activities and services to the local people—small-cost official solutions to meet small groups, targeted activities.

Our health provider communities can be improved simply through greater attention to: strengthening and building local capacity, and encouraging local integration and accountability. Health provider education, service quality improvement and integration of activity is achievable in cost-efficient ways, to in turn achieve a global cost efficiency. Sustainability of local activity needs to be at the forefront. A consistent strategy for quality improvement and the return of accountability for health to the local community is the ideal.

Our Medicare Local, Country North Medicare Local, along with other Medicare Locals have been working to strengthen and build the capacity of local health provider networks to improve the patient journey and to improve outcomes for people. The experiences and lessons from that could be used to improve our systems and the health and welfare of the community—with efficiencies and lower cost as the bonus outcome. Thank you.

CHAIR: Thank you. Ms Lee?

Ms Lee : The Horvath review, which I know you are all familiar with, had 10 recommendations. The Northern Adelaide Medicare Local delivered nine of those with outstanding success. Having gathered up two divisions in the preamble to health reform, we ensured that the collective work and success of over 20 years in our community, the northern outer metropolitan region, were brought along and expanded upon. We did not drop the ball. Instead, we embraced change and the expanded focus, firmly believing that the inclusion of all primary health in this new environment was truly where the change should be focused; not just on GPs, but on all of our primary healthcare providers, our hospital systems and, most importantly, our community.

We did not build an unresponsive bureaucracy. We expanded in areas that—we knew, from 20 years of experience—were under-serviced or completely unserviced. We transferred all of the existing service delivery within our divisions—mental health, Aboriginal health, IT and general practice support—seamlessly. We did not miss a beat. I know that, because our community did not even notice the change.

We ensured that our organisation had a broad and responsive membership base. We set up initially seven membership consortium groups, all of whom were focused around what we knew to be our community population health issues. They were: mental health, palliative care, general practice, older persons in aged care, medical specialists, Aboriginal health, carers and consumers. And, in the last few months, we have expanded those to include disability and childhood, as two new MCGs.

Our MCGs ensure that we have the broadest possible input from all of our stakeholders, service providers, organisations and community, which directly feeds our strategic direction and our needs-assessment analysis. We support them to meet and discuss; we simply ask them to each prioritise what they see as being their top three priorities for primary health in their specific areas. We let them know that NAML, as an organisation, would not pretend to be able to provide solutions to everything, but what we would commit to was ensuring that their priorities were directed to the most appropriate avenues and that, if we could find local collaborative solutions, we would assist in doing so.

We took the challenge of mapping and identifying our local population health needs and gaps very seriously. Anyone can gather data and collate that data; it is what you then do with it that actually matters, most especially to the communities that live with the reality day to day. It is very easy to show that our NAML region has the highest rates of cardiovascular disease, mental health issues, unemployment and children at risk of developmental disadvantage. It is very easy to ask for more funding to address those needs in a seriously disadvantaged region. But to do what with it?

So we employed some great staff—committed and passionate about our region and, more importantly, passionate about the data. It is not a massive team—two people in fact. You will have seen the results of their analysis of our regional data in our submission. But we were not satisfied with that; we then took this analysis back to our community and we commissioned workshops where the community attended, across the age range and social demographics, and we asked them what their lived experience actually was. We asked them to identify the gaps and provide potential solutions. And they did.

They told us that our region lacks: in coordination of care, in information about care and its pathways, in empathy and compassion in the staff they encounter on their patient journey, in affordability, accessibility and in results. They highlighted the needs of those most vulnerable; the aged, the chronically sick, carer inclusion, cultural understanding and transport are multiple barriers to accessing any service. They highlighted the silo mentality of our community services, where there is little or no coordination, let alone communication, and they highlighted how very important this is when you are sick, let alone when you are disadvantaged, vulnerable and alone.

So our organisation, NAML—born out of those two divisions of collective engagement with community over 20-plus years—rightly feels that it undisputedly connected with its local region, its needs, the gaps and the potential solutions. Over the last two years what have we done to embrace the change of health reform and make actual change happen?

We have continued our outstanding engagement and traction in the general practice community. We have continued our longstanding general practice education and training. Expanding that, whilst respecting GP input about targeted education to targeted groups of professionals, we have included all primary healthcare professionals.

We have continued our 13-plus year history of quality mental health service delivery. It is free, and it is delivered from a number of outposts in our region, expanding across the age range and the diagnostic criteria. We have expanded our referral bases from GP only to community and other service providers. We have worked collaboratively with our state local health network, the Northern Adelaide Local Health Network and Country Health SA, to formalise partnerships and determine joint projects to make a real difference; all organisations contributing in-kind, and funding resources. You can see the full extent of that both in our submission and on our website.

I will name just a few that we are particularly proud of. There is our collaboration to reduce emergency department presentations for chronic obstructive pulmonary disease, asthma, those from our culturally and linguistically diverse community, aged care homes, and those who are palliative. Our Living Well with Persistent Pain program provides an eight-month group program for those living with persistent pain. It is a multidisciplinary perspective, responding to the Royal Adelaide Hospital wait list for the chronic pain clinic, which is over three years long with over 40 per cent of those referrals coming from our region. There is also our chronic disease focus, seeking out innovative general practices and supporting allied health providers to tackle issues such as heart disease, smoking, alcohol consumption, perinatal issues and childhood—utilising basic care coordination and pathways as a tool.

There is our education consultant, who works in hotspot areas—schools in communities where children are at high risk of developmental disadvantage—educating the teachers, the school support officers, the kindergarten and the childcare staff to identify and support children with different learning styles, which includes dyslexia.

We are proud of our ability to build, sustain and retain mental health clinicians. Ten years ago this region had no workforce capacity; today it boasts the biggest, highest-quality free service delivery for individual and group therapeutic interventions. We are proud of our CALD refugee new arrival program, working extensively in and with communities to ensure that barriers to access to health care are addressed.

We work with general practice and with individual communities, building and sustaining health literacy and promotion. We have not expanded our service delivery; rather, we have worked collaboratively with our community, all stakeholders and partners, seeking to expand and build community capability, capacity and sustainability. We have provided data, collaboration, facilitation and coordination. We have assisted others to bring funding and fill the gaps to meet our community needs.

In closing, what I would really like to most highlight is assurance and continuity. They are the two things most needed in a constant change environment. My region, the community I live in, is used to change—they are seasoned and cynical. They expect nothing, and most often that is exactly what they get. However, as a healthcare worker, a community member, a health professional by background and now the CEO of a primary healthcare organisation, I would like to see that change. Change is not a bad thing. It keeps us on our toes, but we should be directed and measured by what is needed and how it is achieved—the outcomes locally and how they are measured. We can achieve nothing other than chaos and treading water whilst we wait for direction in change.

For our organisation, the Northern Adelaide Medicare Local, we are committed and passionate about health in our community. We know that what we do is essential to improving the journey, the experience and satisfaction in the outcomes for people living in our community. We know that keeping people well and out of hospital is essential not only to reduce costs, but to improve the outcomes and to intercept acuity of chronic disease which, without early intervention, becomes a major cost to individuals and to health overall. So we intend to be here long into the future doing what we do well in supporting and sustaining our community. What we ask for in this new era of change is some assurance and some continuity and perhaps just a little recognition for what has worked so well. As they say: you don't know what you have got until it is gone.

Mr Seiboth : The Central Adelaide and Hills Medicare Local area covers 12 local governments from the western Adelaide suburbs through the central business district through to the Adelaide hills. It has a population of approximately 520,000 people with diverse cultural and socioeconomic backgrounds. It interfaces with three local health networks: Central Adelaide, Country Health SA and the Women's and Children's. There are a range of diverse primary health providers that provide services to this population, consisting of 850 GPs in 220 practices, 156 pharmacies, 97 residential aged-care facilities and in excess of 1500 allied health professionals. We have also developed relationships with more than 50 non-government organisations, providing community care services.

Central Adelaide and Hills Medicare Local has focused on understanding its population and set about by doing very detailed needs assessment on epidemiological trajectories of a whole range of health presentations throughout the system. Through this comprehensive needs analysis, we were able to focus on some priority areas. The priority areas that were identified by our Medicare Local were in respiratory illness—particularly, COPD—and the range of mental health presentations, with a particular focus on young people, because the region is characterised by a younger cohort as well as very much an aged cohort. Other priority areas were Aboriginal health; childhood immunisation, working directly with health consumers in the healthy weight within Aboriginal communities and the culturally and linguistic diverse communities; care for the elderly in falls prevention; medication management; and oral health. It has also been recognised that end-of-life care was an emerging need that required a response.

Central Adelaide and Hills Medicare Local has very much focused on a partnership arrangement as well as transitioning existing services that were part of the three divisions of general practice that were formally in the region. We successfully transitioned programs such as Closing the Gap, the ATAPS mental health program and implemented after-hours incentives and grants. In the 12 months that we were administering the program, we saw an 11.5 per cent increase in MBS items charged in the out-of-hours period.

CHAIR: Can you just say that again?

Mr Seiboth : During the 12 months that we were administering the after-hours programs, there was an 11.5 per cent increase in GP after-hours services being delivered in our patch.

We were able to establish new services: an exciting new service in partnership with Beyond Blue and Movember Foundation, which was an early intervention telephone counselling service for mental health. We successfully implemented the Partners in Recovery program, providing greatly needed services for people with persistent and enduring mental illness. These were done in a partnership arrangement in a consortium model. We also were able to implement a new headspace service in Woodville, supplying valuable services to the western suburbs. There are a range of other aged-care and preventative programs that have been developed and implemented in the time that the Medicare Local has been in operation.

What we have discovered is that, as my colleagues have spoken about previously, system integration is the key for the future of health services—system integration for all levels of health care but also system integration with the social care networks. Bringing together health care and social care is really the solution to joining up care so that there are better health outcomes for our community.

CHAIR: Thank you very much, Mr Seiboth. I note the closing comments you made, Ms Lee, about assurance, continuity and recognition being critical parts of the practice. We will commence with recognition of the work that you have been doing in each of the Medicare Locals—indeed, all 61 across the country. It is great that you have come to put on the record right now what you have achieved, because, as Senator McLucas has described, the government's management of health seems nothing but chaos, and the uncertainty around Medicare Locals is something that we are very interested in exploring.

Senator WRIGHT: Thank you very much for being willing to give up some time and, Mr Hosking, to travel to be able to give evidence today. I want to place on the record, too, my admiration for the incredibly creative work, I think, that Medicare Locals are doing. Among the things that really interest me are the common elements but also the differences, which show what a creative, responsive approach you are having to the needs of your particular communities. That is really very exciting. So the system integration is obviously what is absolutely important there. Ms Lee, I was aware of the work that had been done by your Medicare Local in terms of the education aspects. You are, as you have indicated, a Medicare Local that caters for probably some of the most impoverished people living in South Australia, given the geographic district that you have. I am interested in exploring with each of you a little bit more about what the chair just adverted to, which is the likely effect of the uncertainty and the move to the Primary Health Network system and what the future might mean for you if it goes in one direction or a different direction. Could you start by just giving us a bit of a sense of that.

Mr Hosking : Yes, there are a lot of unknowns. For our current position, where funding for our core activities—schedule 21 of our flexible funds—ceases in June next year, I think we have a sketch of what the direction is and we are waiting for somebody to apply the colour so that we can see the picture for where we have to go and what will be the end result of the change. There has been an evolution. The Divisions of General Practice had a range of activities that related to community, building capacity and linkage of general practice. The Medicare Locals had their brief expanded to include allied health and more population health planning. If the new PHNs run true to the nine recommendations, which is the sketch, I guess there are positives to be seen out of that, but there are a lot of unknowns at this particular point. It would be lovely to get a sketch with some colour on it.

Senator WRIGHT: There must be a lot of health change fatigue that you are facing, I imagine, both for the people involved—the professionals—and for the communities. Ms Lee?

Ms Lee : Absolutely. I think there is no doubt there is change fatigue, and I am sure I can speak for all three Medicare Locals in that regard. I think the change fatigue is predominantly at the top and, as leaders of organisations where we are leading people who are committed to and passionate about health, we need to model from the top. So we have remained very positive and committed to health reform, which we certainly recognise as being needed. A lot of really great work has been done. I guess what we do not want to see is that continuity and assurance being lost.

From our point of view, what does that mean for us in terms of uncertainty? You would have heard from the previous speakers, from SA Health, that it is very difficult to retain even committed and passionate people in the short to medium term when there is no surety around what might be there for their position. We have a huge concern about the continuity of services. The health department has communicated to us that they too are concerned about ensuring that services continue. However, with all of the programs we run, there is no assurance for any of them. In fact the Medicare Locals have less assurance than some other NGOs beyond June 2015. Medicare Locals have been told that the funding will not go beyond that. But other lead agencies of the Partners in Recovery programs have not been told that. So there is some disparity in terms of continuity.

Headspace faces a huge issue in our region. I know that in the west—across the state in fact—our services to young people have no assurance from anyone that we will remain lead agencies or that those sites will continue with the staff they currently have. We also know that South Australia's early psychosis intervention centres were suspended as a result of the changes. So all of that fantastic intervention that we were so much looking forward to—added psychiatry, hub-and-spoke models with the centre being the Woodville site and with a northern spoke and a southern spoke—has been put on hold. Other states have had those implemented. Ours has been frozen or suspended. So there is a lot of uncertainty and a lot of concern. To the best of our ability, we are not passing that on to the community. We are doing our best to reassure the community that the services will continue. We will do our best to ensure that occurs.

Senator WRIGHT: Mr Seiboth?

Mr Seiboth : I would like to mention that it is a very difficult environment in which to commission services. We were set up as a Medicare Local both to commission a range of service providers as well as, where we identified a market need, to bring in new funds to establish some new services. It is difficult to deal with n environment where programs such as the ATAPs, the mental health program, is only funded for a short period of time. Commissioning service providers requires surety of funding. You have to ensure that you can work with market providers that are tooled up to deliver a range of services, that have the capabilities. However we transition towards primary health networks, there need to be sufficient contracts behind them so that management of the market can be done in a way that gives you the best provision and continuity of care for those in our community who require it.

Senator WRIGHT: I want to call on your expertise—your understanding of your own communities and what the effects on people living in your communities will be—with some of the mooted changes. I understand the recent inquiry into out-of-pocket costs in the health system has indicated that many people are already avoiding or deferring visits to the doctor, or filling scripts, because of cost. Does that accord with your understanding of the situation with the people you work with? What, then, is the likely outcome down the track of making either of these more expensive?

Mr Seiboth : Following the budget announcement in May, there was some correspondence from our GPs in the patch that there was some confusion among their patients in relation to the co-payment and whether it was in or out. That has died down. That was mainly in the first four weeks after the budget announcement. But an indication is that a co-payment does change behaviour. So any additional out-of-pocket expenses are a problem. One of the programs that has been very successful is the Closing the Gap program. It has targeted Aboriginal clients that traditionally have not either filled prescriptions or sought additional health care—due to out-of-pocket expenses. This program, because it has been very targeted towards ensuring supply of valuable medication, as well as additional specialist services, including transport to get to those services, has successfully achieved better health outcomes for those patients. For the most vulnerable, it does require a concerted effort, and any barriers, such as out-of-pocket expenses does prohibit good health outcomes.

Senator WRIGHT: There has been speculation in the media that Medibank Private may want to put forward to tender to run mooted primary healthcare networks. Do you have any views about the appropriateness of a private health insurer tendering to run organisations like that? Would you foresee any risks about conflict of interest? Are there any alarm bells that go off?

Mr Hosking : It guess it goes back to my analogy about the sketch. At the moment, we have a sketch and there is no colour in the picture. So what the involvement of Medibank, any other private or large commercial provider would be, we actually do not know, because we need the colour in the sketch. Going back to my presentation, if we are developing health policy, health policy is something that should be bipartisan. It should be focused on the patient, the person out in the street. Given the cost of it to the global community and Australia, it should be something that is worked out over time and should be measured, reasoned, objective, and is long term. A sketch needs to have colour in it and it needs to be turned into a painting so that we can all understand and interpret, and then we can all know the answers to that sort of question.

Senator WRIGHT: I am just interested as to the things that we should be looking out for. Are there potential conflicts of interest that a particular tenderer would have some interest that may not be able to be managed?

Mr Seiboth : I think all players in the health system need to be involved and around the table, and I concur with Kim's comments. I think that private health insurers in this country are looking for a different role to moving beyond just being private insurers but to becoming health organisations. They need to be engaged and brought to the table so that it is actually integrated care with states and territory governments as well as private providers. We are looking towards the future of bringing the range of players together so that we can respond to health need in our community in a joined-up way.

Mr Hosking : I would just add to that: to adopt a commercial approach to health, one cannot ignore what I would describe as a community service obligation aspect of delivering health. In outer metropolitan areas and country areas, particularly the less populated country areas, applying a commercial solution is extremely difficult, and, where people have gone into those areas as a commercial foray, they have then withdrawn. That is a concern.

CHAIR: Thank you.

Senator McLUCAS: Thank you very much for coming in and bringing your perspectives. I have just had a look at the website. There are five Medicare Locals in South Australia. One of the recommendations of the Horvath inquiry was that primary health networks or organisations should rely on are hospital boundaries in the state or territory. What is the reality on the ground here? What are the boundaries in South Australia around health and hospital districts—or whatever they are called in South Australia.

Ms Lee : Currently, they align very well. There are five Medicare Locals and they align quite well with the LHNs in South Australia. I guess our concern is how many PHNs or what number and what boundaries they might be. Our concern is around how it would align once the numbers diminish, because out understanding is that there will certainly be a lot less.

Senator McLUCAS: How many LHNs are there in South Australia?

Ms Lee : Five.

Senator McLUCAS: So they are pretty aligned already.

Mr Hosking : Four geographic—

Ms Lee : The women's and Children's, which services all areas.

Senator McLUCAS: So four geographic and one whole of state.

Ms Lee : Yes.

Senator McLUCAS: You were referring to services, Mr Hosking, in regional areas. I have just had a look at the size of your region. I did not realise it was everything in South Australia except the bit down the bottom. So I think you are the person I will ask the question about market failure to. We have been trying to pursue this notion of market failure. We talked about it last week in Canberra and thank you for coming to that. What are your views about how to define market failure?

Mr Hosking : It would be dangerous to define market failure just in commercial terms. Market failure needs also to be considered in quality of service. So in our experience, we deliver quite a significant sized mental health support to our region. There are no other providers in our region who can currently do that. I guess, in fairness, if somebody came along and was able to put the same resource in that we have put in they could be competitive. But you want to ensure that the service that is supplied is a quality service.

We have a number of small NGOs that deliver mental health support but they do not provide clinical counsel to patients in need. We provide that service because there is nobody else there that can do it. In our experience, in a small community there may be a local psychologist or a local social worker or a counsellor who we have tried to see whether they could perhaps do this service for us, funded by us, in that community but they are already busy. It is very difficult. People from the metropolitan area do not easily move into the country to do a lot of the work because you need a critical mass to make it a worthwhile proposition for you.

Market failure is commercial but, in particular, it is quality as well. That is a very important consideration and it goes back to my comment about variation. People with similar needs across Australia do not necessarily receive the same support.

Senator McLUCAS: The more I have thought about it, the more I think that the term 'market failure' is an inaccurate term. Prof. Horvath's landing on an economic term to describe a social good is possibly not the right language. Even the department is grappling with the definition, as you would have seen in the frequently asked questions document. But 'service gaps' does not capture that notion of quality. Any old social worker, any old psychiatrist are fabulous—I know that—but they may not suit.

Mr Hosking : The postscript to that would be that we inherited five divisions of general practice systems of mental health. In doing that, we discovered a whole range of things because we had a critical mass or a critical oversight capacity. One of the benefits of pulling together the Medicare Locals, as it currently is, is that we were able to identify differences in funding across regions which we could tidy up. So one of the benefits has been that we have been able to expand mental health services and Closing the Gap services into areas that were not previously serviced. Where the funding was perhaps more than was required, we can shift it into those other areas; we could balance the funding; and we could use the critics of mass of the organisation to move staff where there is a shortfall. We can be flexible to account for need on a community-by-community basis rather than by other ways.

Senator McLUCAS: Ms Lee, about the history of your Medicare Local and the GP division previously, a concern of mine is that this language that we need to move to GP led primary health networks seems to imply that whatever is there now is not good and that there is a deficit there. My view, and I am a former member of a division of general practice. I represented the community in 1995 in one of the first divisions of general practice in Cairns so I have seen that transition too. I think that Prof. Horvath's comments are constructing a demarcation that is long gone, that is well and truly over. I was very interested in your Northern Region GP Council. So you have got GPs clearly there and in the game, playing and part of the story. Is that a reasonable assessment of South Australia's transition from divisions of general practice to primary health services, where everyone is playing?

Ms Lee : Absolutely. We have brought our GPs with us and they have not noticed the difference, quite frankly. They are still getting the services that they got before, and we are including all the other primary health care providers as well. So there are different opportunities to take part in. There are various programs, education, events and clinics. Our pain clinic is a perfect example of that. Sure, we have got GPs in there but the patient is at the centre of that and there is a whole team of allied health professionals including the GP actually caring for those patient needs. That council has been in existence for 2½ years and is contributing an enormous amount to South Australia Health and to various other committees around providing general practice input and advice.

Senator McLUCAS: We had a witness here yesterday who said that rather than 'GP led', we should have 'consumer led' primary health services, which is a nice thought. Are all of you lead agents on the Partners in Recovery program?

Ms Lee : Our region was not successful. Our Partners in Recovery program was suspended in that round. We actually do not have that much need of that program in our region.

Mr Seiboth : Yes, we are a lead agency.

Senator McLUCAS: Mr Hosking, are you too?

Mr Hosking : Yes, we are.

Senator McLUCAS: I have been receiving calls in my role as shadow minister for mental health about organisations having to close their books because of the uncertainty. Without talking about your own service—I do not want to cause concern in your community—do you share those concerns in the programs that you are running?

Mr Hosking : Yes we do. It is not just Medicare Locals that are in this particular boat at the moment.

Senator McLUCAS: That is a good point.

Mr Hosking : Pretty much everybody that we know in our region has a contract expiring at the end of June next year. The level of uncertainty is not just for the Medicare Locals; it is right across the board. So we have an uncertainty in relation to Partners in Recovery. I am not sure that that same uncertainty exists in organisations where the Medicare Local is not the lead agency. I am not aware that they have been given the same instruction that we have. We have an uncertainty about where we would go with Partners in Recovery but some of our consortia partners are in a similar boat: they are not sure what their future is beyond 2015.

Senator McLUCAS: Are you aware that the frequently asked questions document that the department has put out says it is appropriate to adopt a 'worst case approach' when dealing with schedule 38?

Mr Hosking : Yes.

Senator McLUCAS: That is pretty concerning.

Senator CAMERON: I want to go back to the Horvath report that you raised in your opening statement, Ms Lee. Yesterday when Dr Stephen Duckett was questioned about the Horvath report, he described it as 'confused' and 'peculiar'. I suppose, to be a bit diplomatic, it is probably not one of his finest pieces of work. Tell me a bit more about this report. I have read it and I cannot see any factual basis for the recommendations other than—if you read the AMA submission—it has basically picked the AMA submission up and transplanted it into his recommendations. Would that be a fair analysis?

Ms Lee : I think that when the Horvarth report was published, in the first read of it you could very easily take it as a congratulatory statement for what Medicare Locals had achieved. I guess the confusion, certainly for our organisation, was why there was a recommendation to move to new networks and wind up or withdraw funding from Medicare Locals when, as I said in my earlier statement, we have achieved against each of those nine recommendations in an outstanding way. I suppose the additional comment I would make to that is that we obviously were all able to put in a response to that review, which we all did. However, there were very few, to my understanding, Medicare Locals actually visited as part of that review. Perhaps the recommendations and the facts contained within that review come from those particular Medicare Locals and particular areas of submission that were of interest to the review. It certainly does not reflect our understanding of what is happening in our Medicare Locals in South Australia.

CHAIR: So are you saying that it is a distorted sample size that informed the Horvath review?

Ms Lee : You could draw that conclusion. It certainly was not a fair representation of Medicare Locals across Australia that were contacted or visited.

CHAIR: Do you know how many were?

Ms Lee : Not off the top of my head, no.

CHAIR: Can you give us a rough number based on the conversations you have had? We will follow it up.

Ms Lee : My understanding is that there were between six and 12 that were actually either contacted or visited.

CHAIR: Thank you.

Senator CAMERON: I want to go back to the AMA submission because the AMA submission—and anyone can answer this if you have read it—was based on surveys of 1,200 GPs, which would be, I think, a fairly robust sample of GPs. You could do 1,200 on a poll across the nation and that can get you some credibility. So 1,200 GPs is a pretty significant poll. They were very critical of Medicare Locals in that poll and in their report. They came up with a range of recommendations that I think have been picked up by Horvath without any further analysis. They were calling them PHCOs in their report—that is, what replaces Medicare Locals. They say they have to be GP led and locally responsive. There have been other analyses that said a GP approach is an old-fashioned, narrow approach, that you have to look at the whole basis of care. It is not just GPs; they are very important, but it is not just them. So they are arguing that it has to be GP led and locally responsive. What is your view on this?

Mr Seiboth : I have two comments. First of all, going back to the AMA sampling of GPs, the methodology would not be without bias because it was not a random sampling of general practice to get a broad range. So what invariably happens is those who have the strongest opinions would respond to any survey rather than a structured approach where you would get a statistical analysis from a representative sample across the profession. I would like to make that comment. In terms of GP led, it is undeniable that general practice is at the heart of primary health care and the way that our system operates, with strong connections with a local primary care provider, a local GP, that often can coordinate other elements of the system through various levels of research, indicating that that is the approach we need in our healthcare system. In terms of GP led, I think there is an important distinction between understanding the role as a practitioner versus leading a healthcare organisation. Leading a healthcare organisation is a specific skill in itself, and I think these need to be brought together so that you have the intelligence, the experience and the methodologies of integrating care with the advice and the clinical input from the general practice profession. But it cannot exclusively be general practice without looking at what is required to integrate care.

One of the learnings that has been part of the Medicare Locals is, yes, the range of other disciplines that are involved in primary care from allied health to nursing, but an important feature has also been the specialist components that are sitting in the public hospital but also in private hospitals. Integration requires all these clinical inputs to be brought together with the advice of citizens, consumers et cetera to then design what are the best health responses to respond to the health needs.

Senator CAMERON: Could you, on notice, collectively, if that is possible—or individually, if that is preferable—have a look at the AMA submission to the Horvath enquiry and the Horvath recommendations and provide us with an analysis of the issues that this raises in the context of allegations about your performance, because this is the issue. They say in the AMA correspondence to the secretary of the department that:

There has been a deliberate effort to down play the role of GPs and many Medicare Locals have failed to communicate effectively with general practice, or engage with them in a meaningful way. The performance of Medicare Locals against their objectives has been patchy and there appears to be little evidence of improvement on the former divisions of general practice structure that they have replaced—despite significant additional funding.

That to me is the core of the attack on Medicare Locals. For this committee to have a view, I think we need to get your view, specifically on this analysis of alleged poor performance by the Medicare Locals and lack of engagement with the GPs. Is it possible to do that?

Ms Lee : Absolutely.

Senator CAMERON: If you could do that and when you get back to the secretary with your additional report, indicate whether that is collective or individual response, so we know what is going on. I think I might leave it at that—there is much more I could do here. The submission I have is called 10/222, to Jane Halton, dated 19 September 2013. I could probably flick that to the secretary, and he can properly get it to you.

CHAIR: I am plumping for them doing a collaborative report. It looks like that is the way they work.

Ms Lee : We are very happy to do a collaborative report; absolutely.

CHAIR: They are into integration and collaboration, I think. What is the FTE workforce and cost to wind up your Medicare Local?

Mr Hosking : Around 100 employees, probably 75 FTE and $1.9 million.

CHAIR: Ms Lee?

Ms Lee : Ours is about $2.2 million, and we have currently got about 70 employees, about 65 FTE.

CHAIR: Mr Seiboth?

Mr Seiboth : Sixty FTE and $1.2 million to wind up.

CHAIR: I noticed in the Northern region submission you spoke about the medical specialisation. We just got to a little bit of that evidence in the end. We have not really had much about access to medical specialisation, so if there is any further material you could provide us with, I think that could be very helpful for us.

Once again, thank you for the work that you have already achieved; for the leadership that you have shown the community; and, undoubtedly, for the health outcomes that you have improved for thousands of South Australians. We look forward to your next submission. Thank you.