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Senate Select Committee on Health
09/10/2014

JONES, Associate Professor Martin, Director, University Department of Rural Health, University of South Australia

CHAIR: Welcome. I invite you to make a brief opening statement, and then the committee will have some questions.

Prof. Jones : Thank you very much for asking me here today. I am delighted to be given this opportunity to share some of my experiences, insights and observations. I suppose I would first like to state that, since coming to Australia, I continue to be surprised that people living in rural and remote communities have shorter lives and higher levels of illness and disability. In the 12 months I have been here I have also observed in rural communities how a lack of health services constrains community growth and how important it is to build an available and work-ready workforce. On the positive side—and I find this a very humbling experience—I have observed how Australians living in rural communities are incredibly generous with their time to build the community, such as volunteering and community belonging. It is an experience that, to date, I have not experienced in the United Kingdom. In terms of some of the areas we are going to talk about over the next half hour or that I could potentially share with you, I am going to talk, as I have been asked to, about some of the risks in the reductions in Commonwealth expenditure. But I will also talk about potentially some of the solutions, because I am aware that we are in a reduced financial envelope, and about how we can manage and adapt in that situation.

To tell you a little bit about me, I have been in Australia for 12 months. I am Director of the University Department of Rural Health. It is a successfully funded Commonwealth program, and our role is to enhance and expand the rural and remote mental health workforce. We are the only based academic unit that works with all the health disciplines—undergraduate, postgraduate and the existing workforce within rural and remote Australia. There are 11 of us across Australia, which, I am sure, colleagues are already aware of. Before I came to Australia I had spent 28 years in the United Kingdom. My primary focus there was workforce planning—in particular, how we could prepare professionals to undertake new roles, such as preparing nurses to prescribe; service redesign—moving from an institutional based system towards caring for people in their own homes; service evaluation—in particular, understanding how we can prepare professionals, clinicians and non-professional healthcare workers to do their job a little bit differently in terms of preparing them in evidence based training; a little bit of professional leadership; and also understanding about governance and putting governance structures to give us assurance that the care we are providing is safe and of a reasonable quality.

I have gone through your terms of reference and I have made some observations in each of the terms of reference. The observations I have made are through the lens of my current role in the University Department of Rural Health but are also informed by my experience in the United Kingdom.

CHAIR: Thank you very much, Professor, for your participation and for your response to the terms of reference. It really helps us in seeing where your thinking aligns with the things that we are inquiring into.

Senator WRIGHT: Thank you, Professor Jones, for being prepared to come along and share your insights and your experiences with us. That is very helpful. It is good to hear what you have found about country Australia. I am interested in the disproportionate impacts that the proposed changes—the reduction in hospital funding and the introduction of some of the charges like the Medicare co-payment and the increased cost of visiting specialists and of having prescriptions filled—will have on people living in rural areas and, being a South Australian senator, particularly in South Australia. I am interested in whether you have any information you can provide us with about the burden of disease and how that impacts people in rural areas in South Australia compared to metropolitan areas, and perhaps we can take it from there. I am also interested in the demographics—average incomes and things like that.

Prof. Jones : In terms of the introduction of the co-payment, it will have a disproportionate impact on people from lower socioeconomic backgrounds, and this is a group of individuals who will already have a higher propensity towards long-term conditions. Obviously—you can work it out for yourselves, I am sure—if you have a lower proportion of income, you are going to put off the visit to a GP to get your specific ailment treated. You are going to avoid going to a GP. But if you delay seeking help, particularly when you have got a long-term condition, whether that is a mental health condition such as schizophrenia or a physical health condition such as diabetes, it is very likely to end in a crisis because that is a natural course of what happens with a long-term condition if you do not get it treated—you relapse, you become poorly again.

The outcome of that will be an increase in admissions to hospital, and being admitted to hospital is the most expensive intervention in the healthcare system. But also it is very harmful as well. Going into hospital takes you away from your friends, it takes you away from your family. If you are working, it puts your income at risk. It may well put your housing and your tenancy at risk. Also, when you are actually in hospital, the skills of living are taken away from you. Very often you come out of hospital and, arguably, your condition may well have been treated but it has had a disabling effect upon you. So that is a potential risk in terms of what is being proposed.

Already in Australia we have a rural metropolitan gap in terms of health. It is much more difficult to get access to services and there are greater distances to seek help. I also have got concerns about the disproportionate impact on people's serious mental health problems and chronic conditions. People with schizophrenia already die between 10 and 15 years earlier than the general population. This is not unique to Australia. It occurs right across the Western world, which is a challenge for all of us, and it is arguably a human rights issue. Making services that much more inaccessible for arguably treatable and modifiable conditions may have a disproportionate impact, because the reason why people with schizophrenia die earlier is for modifiable factors such as people do not get down to the dentist, people do not get down to the optician, people do not have conversations with their primary care clinician about lifestyle changes and things like smoking and all that type of stuff.

But also I have got concerns that this may well disproportionately impact on people with an increased propensity to chronic conditions, which people in rural and remote communities do experience. For example, if you have cardiovascular disease, approximately 25 per cent of people with cardiovascular disease will become clinically depressed. We need to be concerned about this because, as well as being pretty unpleasant for the sufferer and the family, it directly impacts on the cause and outcome of cardiovascular disease. For example, it results in an increasing likelihood that you will have future cardiovascular events and also has a disproportionate effect on your quality of life. That propensity towards long-term conditions goes hand in hand with an increased risk of depression. That is why I would be concerned.

In terms of some of the solutions, we could potentially do a holistic impact assessment—I suppose this is what a lot of this is all about—but we can also think about what we can do with our current workforce. What has emerged from the evidence is that around 50 per cent of people with long-term conditions are non-compliant with treatment. That is despite a well-developed evidence base that, if our clinicians have a conversation using certain principles, patients and their families are much more likely to stick with treatment. Those are some of the things I would ask colleagues around the table to think about in terms of how we can utilise our existing workforce in rural communities to help people with long-term conditions to stick with treatment.

Also what I have picked up in Australia is that you have a much broader mixed economy of care here. Where I come from, we tend to have a monopoly of care, with 90 per cent of care provided by the NHS. That certainly provides advantages, but there are disadvantages too. Here in Australia you have a mixed economy approach. You have a whole range of voluntary sectors. There is a real opportunity there in terms of how you can prepare and support that sector of the health economy to think differently about how they can support people in rural and remote communities with long-term conditions.

One of the areas I was really surprised with but also very appreciative of when I opened my own UDRH and also from visiting other UDRHs across Australia is that we get 500 or 600 young people training to be healthcare professionals coming to our communities every year. These are talented individuals who are incredibly generous with their time. We have an opportunity here—and Broken Hill UDRH has really developed this—in terms of developing the concept of 'service learning'. Maybe, instead of using these individuals to go down the traditional tertiary route of putting them into wards and stuff like that, we can utilise their skills and expertise in much more preventive ways. Maybe we could look at what we can do with speech therapy students in the area of skills in kindergartens, for example. Maybe we could look at what we can do with occupational therapy students to undertake specific projects to build the health and wellbeing of the community. Maybe we could look at what we can do with physiotherapy students in terms of going into specific industries. In Whyalla we have a big steel industry. So maybe we could look at what we can do to offer students experiences there so that they can actually go into the workplace and offer preventive intervention. So UDRHs are key players in the potential furniture here, in the economy, to utilise the expertise that they have in terms of the young people coming into a community in a much more preventive evidence based way.

Senator WRIGHT: Can I ask you a bit more about the workforce. Attracting and retaining workforce in rural areas is a real challenge in Australia. In the mental health area, and generally speaking, a lot of trained people live in urban areas. One aspect of workforce attraction and retention that I understand to be pretty effective is 'grow your own'—there is a high success rate where people who have lived in rural areas become trained and come back. Or, ideally, they would just stay there—because often if they go away to the cities they do not come back. This is a slightly tangential question but I think it is relevant. Are you aware of any concerns with the other UDRHs, particularly where there are significant regional universities in Australia, about the possible consequences of changes to funding arrangements for universities? This could mean that some of those regional universities which may be training workforce who will live in and stay in their areas may be effected. Are you concerned about that as potentially having a blow-out effect on workforce availability in rural areas?

Prof. Jones : In terms of the disbandment of HWA—is that where you are coming from?

Senator WRIGHT: There have been a lot of predictions that the proposed funding changes and deregulation of the university market will have a particularly adverse effect on regional universities. It seems to me that they are the universities that our training up the professionals who stay in those rural areas. They are a really vital part of rural areas. I think it is linked. I think there is a bigger picture here that we need to be aware of if we are talking about trying to get people who are trained to stay in rural areas. Has anyone been drawing those links at this point? Is there any concern there?

Prof. Jones : There is a well developed evidence base called the Rural Health Pipeline. If you get information about healthcare careers into the schools, people are much more likely to go into universities in their local area. Also the challenge is: what can we do to give people good clinical experiences in the rural regions and help those clinicians to have a fulfilling professional career while they are actually here? That is the challenge we have got—to sustain that Rural Health Pipeline. In terms of the threats to that, what we have experienced in Whyalla, and in the department, is that Adelaide tends to suck our young people away. Young people get attracted by the bright lights of Adelaide and other cities. However, if we can actually give quality clinical experiences in rural and remote Australia, what the evidence tells us is that those individuals tend to come back. However, if we do not offer that those quality clinical experiences—not just in tertiary but across a whole portfolio—we tend to lose those individuals to the big cities. That is arguably one of the reasons why we seem to have this inequality in terms of health between metropolitan and rural and remote Australia. So the challenge I see, particularly in rural and remote areas, is: what can we actually do to build the experiences for students to make it an attractive place in which people might want to undertake a placement? We must almost give people a portfolio of opportunities—whether it is a tertiary placement or working in a kindergarten assessing speech deficit in children and assisting parents and teachers and enabling those young people to actually get into primary care to get their speech deficit treated.

Senator WRIGHT: What effect do you think the cuts to the preventive health programs will have, particularly for people living in rural Australia? Will there be a disproportionate impact on people?

Prof. Jones : Similar reductions announced the cessation of national partnership agreements in preventive health and public dental services. Logically, if you follow that progression it will result in delays in treatment. As I mentioned at the start, delays in treatment for people with long-term conditions tend to exacerbate chronic conditions—whether it is diabetes, depression or cardiovascular disease. Also, a vicious cycle emerges then: if chronicity increases in the community you then get an increase in depression; once you develop depression with your chronic condition, your quality of life decreases; and as a result of having a decreased quality of life and the exacerbation of your chronic condition, you are much more likely to consume much more hospital resources, which is really not the direction you want to go in.

Senator McLUCAS: Thank you very much for coming to speak with us again, Professor Jones. I want to go to issues around Medicare Locals and, in particular, the Partners in Recovery program, for which most Medicare Locals have become the lead agent. I know this is outside of your role, but I dare say your passion around mental health might have given you some experience here.

What is your assessment of how those programs have rolled out, but also these chaotic circumstances we have at the moment with Medicare Locals being defunded, Partners in Recovery maybe moving, the whole Mental Health Commission's review of mental health programs and services happening all on the same time? What is your take on the landscape at the moment?

Prof. Jones : I share your observation that there is a certain degree of chaos at the moment in my part of the world, when I am working with the governance staff of Medicare Locals in terms of their future and where they are going to fit, and who is going to be their new provider. Certainly at UDRH we are looking for a strategic partner to work with in that area because we are very keen to sort out what we can actually do to build clinical experiences for our students who come to our communities. I see them as a key preventive agency. I fully understand that the government has come into office and wants to have a look at things. I would say that if you could use your influence just to get it fixed as soon as possible, so we could have some long-term strategic partners whom we can work with, particularly thinking about what we can do with those partners to build the clinical experiences. In terms of mental health and mental health prevention, it is another reason why we need to get things fixed. Twenty per cent of Australians will have a mental health problem for which they will seek help from their primary care team, which is why it is important that, when the new primary care services are developed, we have them in place and there is a clear focus and attention on their overall mental health strategy.

Senator McLUCAS: I understand your point about doing it as soon as possible and getting that timing happening. My concern is the decision that we now have to ditch Medicare Locals—because the government does not like Medicare, so they clearly do not like Medicare Local. That is the first thing. There is a program that has been put in place to move from Medicare Locals to primary health networks. It is almost like an afterthought that someone has said, 'Hang on, aren't most of these Medicare Locals lead agents for Partners in Recovery?', and at the same time we are doing a big review of mental health in Australia. It is the transition that is worrying me. It as been brought to my attention that some Partners in Recovery programs have had to close their book because there is no certainty about the future. So they do not want to take on clients with significant mental health issues to be addressed, to drop them again in six months time, which is the last thing a person with a mental illness needs. Have you heard of any of that?

Prof. Jones : I have not heard of any of that in my part of the world, though I can see how that may well happen due to the uncertainty of what is going on at the moment. I suppose that coming from the region, we would like some clarity and a clear roadmap and a timeline in terms of how this is likely to be resolved.

Senator McLUCAS: Thank you.

Senator CAMERON: One of the witnesses who appeared yesterday was, I think in an offhand way, a bit critical of the UK health system—the peak body for radiographers and radiologists. They predominantly operate on a for-profit basis, with individual companies being established. They have been the only organisation that has looked like they are going anywhere near supporting the $7 co-payment because they have another agenda that they want to run. What I am interested in is their argument, which I think was that you cannot go to a big wealthy estate type health system because there is this flight of talent from the UK, and you might be one of them.

Prof. Jones : And you, if I listen to your accent.

Senator CAMERON: I am only a fitter; I am not a medico. I would like your comment on that. One of the other pieces of information we got was how the co-payment affects people going in and receiving frontline medical assistance early. It shows the UK and Scandinavian countries down the bottom because there is not a co-payment there. So people are getting in early. Have you got some views on these issues?

Prof. Jones : Yes, I have had 28 years experience in the UK and the NHS. I suppose the first thing to say is that there are probably four types of NHS in the UK now to reflect the devolved governance in the United Kingdom. I come from very much the English perspective and I would say in terms of a quality and a governance framework, it is robustly regulated by the Care Quality Commission. It has a very robust quality assurance framework which gives the public assurance in terms of what is working and what is not working. The public are extremely well informed now, certainly across England, about which trusts or NHS hospitals are working well, or which NHS hospitals are not working so well in terms of quality and safety. I would say that is a world-class system, that sort of uniform approach which occurs across the United Kingdom.

One of the things which struck me across Australia being a user services when I have gone to see a GP is how easy it is to see a GP here. It is very easy to see a GP and also a clinician on hospitals as well. It seems to be here that the method of paying clinicians to see patients works. You get people into the system incredibly quickly while in the UK, and particularly in the NHS, clinicians are salaried so they only see a set number of patients and they will sometimes find creative ways to stick to that quota of patients whom they are expected to see. I think the potential downside in Australia which you need to work on, or we all need to work on, is, with the increased flow of patients to see GPs, what quality governance structures can we put in place which gives us an assurance that the public get a quality experience when they are seeing a GP in terms of respect, dignity, safe use of medicines, if the patient develops any adverse effects how that is being monitored and if there are any major safety issues. For that sort of collection of individuals in a primary care service which works incredibly well from a patient throughput, maybe we need to work a little bit more on the quality perspective in terms of what assurances the public have that the GP down the road will deliver the same services as another GP and that the public can make a choice. So instead of just thinking about it from a financial point of view, they can think about it from a quality point of view.

Senator CAMERON: I am not sure if you followed the Medicare local debate closely or whether you have actually seen the AMA's submission to the Horvath review.

Prof. Jones : No, I have not.

Senator CAMERON: That submission was basically saying that everything must revolve around the GP. The other argument we have had here is that that is an old-fashioned view. You have all these ancillary skills that help GPs or are distinct from a GP but can help a patient. You have to look at that broad-based service delivery not just through the GP. Would you have any views on that?

Prof. Jones : Yes. I come from a mental health background where over the last 10 or 15 years we have moved from a scenario where the psychiatrist was the centre of the team and was very much seen as an answer to all of our troubles to, increasingly, where those skills were shared across the team, very much moving towards a team-based viewpoint—for example, where we would have radiographers assuming prescribing responsibilities, where we would have district nurses assuming prescribing responsibilities and different clinicians. Obviously it would be within their scope of practice, doing interventions and approaches which previously would have been done only by medical colleagues. When I speak to medical colleagues they get a little bit anxious about that. Again, some of the work we have done in the UK in looking at patients' experience of nurses undertaking prescribing responsibilities shows that what they generally want is access to medicines a lot quicker for things like a throat infection. However, if someone wants a specialist opinion then they want to see a consultant psychiatrist, for example. But predominantly we are moving into the domain of long-term conditions, where a lot of the medicines we use tend to be repeat prescriptions. What the public wants is just accessibility of those medicines at a time which is convenient to them.

So there are fantastic opportunities, if the will is there, to think about how we can share these responsibilities, which previously have only been tied up within one professional group, across the other disciplines. From a UDRH perspective, that would really give opportunities to attract future healthcare professionals in terms of future career development and future career growth, especially in rural and remote communities, where people might have to travel four hours to see a GP in some of our communities. If we could think differently about how we can use our other allied healthcare professionals, they would not have to go through that experience.

Senator CAMERON: My practical experience with this stuff was in a place called Tamworth, which is in north-east New South Wales. Tamworth city is a big rural city. Outside it, about five or six kilometres away, there is a big Housing Commission area. In the Housing Commission area, they cannot find any doctor to bulk-bill. In fact, in Tamworth and generally in rural areas, getting a doctor to bulk-bill is almost impossible. So what is happening up in this working class area outside Tamworth is that you have the University of New England providing student doctors to the healthcare centre along with a nurse practitioner, and that is it. So for most of these working class, low-socioeconomic people, including Indigenous groups, in these Housing Commission areas that is their only access to health. I do not think that is really good, and this goes against the argument you were making that people can get access pretty easily. Don't you agree that you can get access if you have money but, if it is not bulk-billed, if you do not have the money to do it then you cannot get access?

Prof. Jones : You are right: Australians who have a high degree of income can get access. They can get a flight down into Sydney to see a private physician.

Senator CAMERON: Yes. So I just want to qualify the position you are putting.

Prof. Jones : Yes, but let's look at the evidence here. If you look at other countries in the world where this and other responsibilities have been devolved to other clinicians, it has been viewed incredibly positively by patients. If you look at the United States, where prescribing responsibilities are pretty much embedded in the nursing profession, in terms of adverse effects and things going wrong, you are much more likely to have a prescription from a physician which goes wrong than from a nurse. The reason for that seems to be that nurses have the fear of God put into them in terms of adhering to a very rigid protocol. So again the evidence does not stack up for a poor-quality healthcare experience if the appropriate clinicians have had the appropriate training and supervision. From a quality and safety perspective, there is no difference.

Senator CAMERON: Is there any academic analysis that is seen as the best analysis on this issue that we could look at? What are you basing your submission here on on that issue of clinicians?

Prof. Jones : It is basically on the nurse prescribing literature. If you look in the UK, there is quite a well developed evidence base on nurse prescribing now. There are a whole range of funded Department of Health studies which show that, whether it is a physician—a doctor—or a nurse who does your prescribing, there is no difference in the quality of the medicine prescribed, in adverse effect or, indeed, in the experience. In the United Kingdom we have only been going 10 years now, but if we look in the United States, where it has been going 30 years, we have a similar picture emerging. In terms of psychiatry, just moving away from the prescribing agenda, previously it was a psychiatrist who made a decision whether to admit someone into hospital. It was seen as a psychiatrist's role and responsibility to do that. We have now moved towards teams making an assessment of whether someone should be admitted to hospital and we have developed so-called a concept of a home treatment team. That has now been going for 10 years in the United Kingdom which, again, shows a very robust evidence base in terms of not only patient safety but also reducing the need of people being admitted to hospital. The pattern emerging here is when that responsibility is devolved to other disciplines patients are much less likely to get admitted into a tertiary bed.

Senator CAMERON: The single biggest workplace accident area in Australia is the rural sector. I do not know if you are aware of that?

Prof. Jones : Yes.

Senator CAMERON: Farming as an industry, agriculture as an industry. There is a general view out there that mental health issues and suicide are huge in rural Australia. I wonder whether any work or analysis has been done as to whether this massive number of agricultural deaths are actually mental health associated issues as distinct from purely an accident?

Prof. Jones : Let us unpick this a little bit. Rates of depression in metropolitan Australia and rural Australia are probably the same. There is probably no difference. However, suicide rates in rural and remote Australia are higher. The farming community is an occupation which seems to be at a higher risk. That is not unique to Australia, by the way; a similar pattern occurs in the United Kingdom. However, a consequence of untreated depression is an increased risk of suicide. I think we come back here to accessibility of services. Again, if you look at the farming community, you will see that it might take four to five hours to see a clinician. So this is a group of individuals who have additional challenges and hurdles to overcome to go and see a clinician. This is despite a very well-developed evidence base to treat depression. We have got antidepressants. Approximately one in three people will have a positive response to an antidepressant if they are depressed. We also have got so-called cognitive behavioural therapy, which is a kind of a talking approach to help people with depression. Also, what is emerging—I know I am going off topic and I will come back to the farming question in a minute—is that there is now a well-developed evidence base in terms of ECBT—electronic cognitive behaviour therapy. So there are opportunities to actually take that as a method of treatment into the regions, as well as seeing a therapist.

In terms of the farming community, that is really interesting and it is a real challenge for Australia. It is a group of individuals who contribute an enormous amount to the nation's GDP. But it is also an occupation which has a much lower life expectancy. There are all sorts of assumptions: is it because this group is much more stoic that they generally put off getting help? There are a whole range of research and understanding which need to go into that area. We are currently doing some work at the University of South Australia looking at the health literacy of this population group in Australia in terms of what to do if they feel they might need some help. There are a whole range of deeper understanding that we need to understand with respect to the expectations of services for this group. We as a country have a responsibility to actually make ourselves much more available to that occupational group and recognise the real difficulties that this occupational group has in accessing services.

Senator CAMERON: In terms of the budget cuts in health, what are the implications for rural and regional health?

Prof. Jones : I have made some notes.

Senator CAMERON: You were expecting that one, were you?

Prof. Jones : Yes. It has a disproportionate impact on people with long-term conditions. Rural and remote communities are an area which have a higher proportion of people from lower socio-economic backgrounds and that profile seems to indicate a greater proportion of chronicity. Yes, it will have a disproportionate effect on people in rural and remote communities. However, I am aware we are in an environment of a reduced financial envelope, so we do have to think differently in terms of how we can utilise our reduced resources. How can we better utilise these hundreds of students who come into our community every year with a whole range of expertise, for example, in the development of student clinics? How can we prepare our existing workforce in the community to do their jobs a little bit better by utilising the evidence, as I mentioned earlier. About 50 per cent of people with long-term conditions are non-adherent with medicines or non-adherent with treatment. If you are non-adherent with treatment in medicine you become poorly again. How can we prepare our existing workforce to maybe focus a little bit on helping people to stick with treatment?

You have also got an interesting developments now with new technologies, as I mentioned earlier the ECBT, to deliver health care. Also, the opportunity we have to almost break away from the shackles of the medical model in terms of thinking: how can we encourage our existing professionals and our existing healthcare professionals to take on responsibilities and roles previously done by other disciplines?

CHAIR: I note in your comments you have indicated twice the concerns about constraints around health system costs. This is a discourse that is very much alive in the political milieu of the time. We have had evidence from a number of witnesses during the hearing thus far, and indeed today from the nurses union, about a new report by the Australian Institute of Health and Welfare which really gives lie to that sense of there being straitened conditions and that actually the cost of the health system is in pretty good shape. Obviously, we always want to be careful with the way that we use resources but this sense of a health crisis, which we are increasingly being told, is a misrepresentation of our financial reality. I thought you might be interested to have a look at the particular report and the one from the nurses.

Prof. Jones : Yes.

CHAIR: I also note in your comments you indicated that you responded to the terms of reference in your preparation for today. We have not traversed all of a. to h. and I suspect that in the notes and the pages you have been flicking through there are some gems of wisdom that we have not got to today, so I invite you to formalise that and send us any additional information or indeed recover some of the themes. If you could write it up and send it to us it would be very helpful. Can I ask you to put on the record: in your view, what do you think the abolition of the National Preventative Health Agency is likely to do to health access and health outcomes for Australians?

Prof. Jones : Since coming to Australia, I would say you have got some world-class examples of preventive care in terms of tobacco cessation. Your communities work together to help Australians cease smoking. Also, your Closing the Gap initiative where you have had a whole-of-government, community, Australian approach to reducing some of the predictors of poor health amongst the Aboriginal community is something to be proud of. I know you have still got a lot of work to do, which you do recognise as a country. But it is heartening to see how a country is taking a whole-of-country approach to do that. In Australia you have got a whole range of expertise in preventive care to draw upon and you have an evidence base as well to support that. That is the good news.

In terms of the preventive health reductions, as I said before, the constant theme of my argument today is that this will result in significant delays in treatments for people who have particular problems in the area of long-term conditions. I see that as a major risk of the proposed changes.

CHAIR: Thank you for your time and for sharing your knowledge with us today, Professor Jones. We hope to hear from you in written form with the things that we did not get to cover with you today.

Prof. Jones : Thank you.