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Senate Select Committee on Health
09/10/2014

MITCHELL, Ms Amanda, Health Development Coordinator, Aboriginal Health Council of South Australia

MOHOR, Mr Shane, Acting Chief Executive Officer, Aboriginal Health Council of South Australia

RYAN, Mr Paul, Senior Project Officer, Member Support, Aboriginal Health Council of South Australia

[13:44]

CHAIR: Welcome. Ms Mitchell, you are seeking to table a document?

Ms Mitchell : Yes.

Senator McLUCAS: I am happy to move that the committee accept the document.

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

Mr Mohor : Thank you for the opportunity to respond to the committee's terms of reference. The Aboriginal Health Council of South Australia is the peak body for Aboriginal health in South Australia, representing Aboriginal community controlled health services and the Aboriginal health advisory committees. The Aboriginal community controlled sector has been providing services for the Aboriginal committees for over 40 years. AHCSA believes that the ACCHS are the most effective, efficient, safe and culturally appropriate means of continuing to make inroads into the health disparities between Aboriginal first nation peoples and the general population in South Australia.

AHCSA believes that the ACCHS have the infrastructure and the networks which provide for a coordinated and integrated primary healthcare system for all Aboriginal people and therefore are better positioned to offer primary healthcare services than mainstream services. The capacity and history of the ACCHS sector should be recognised with maintenance and the growth of investment as a cost-effective way of closing the gap. By doing this, AHCSA contends that further inroads into improving outcomes for Aboriginal people can be made in cost-effective, safe and equitable ways. That is just a brief introduction. Our chairperson, Mr John Singer, is unfortunately not able to attend. He is the director of Nganampa Health Services in the APY Lands. As has been the case over the last four weeks, there have been significant deaths in the community that have been family related to John, so he is in apology and once again it is another demonstration of our communities experiencing grief and loss on a daily basis.

As an introduction to who AHCSA is and what we stand for, we are also represented from community. The impacts of death, grief and loss happen on a daily basis. That also contributes to how the services run and how effective they are, as a result of the hard work they do on a regular basis, based on the continual grief and loss that is experienced across the country, particularly in South Australia.

CHAIR: On that note, can I formally convey the committee's condolences to John and his family and kin for the loss that they are currently experiencing. It is very saddening to hear that it is a continual part of the challenges facing the community, amongst many others. We are very pleased that you are able to join us today and thank you for your submission. What do you think will be the impact of the proposed change to access to GPs by putting a $7 tax on people to see a GP? What do you think that will do to the community that you represent?

Mr Mohor : As an immediate response, on page 5 of the document, there is a dot point that covers three areas immediately regarding the introduction of co-payments. My first opinion is that it probably will not close the gap, and in terms of the health outcomes they will be widened based on an introduction of a co-payment. The health care and administration costs that will be incurred not only by the individual but by the government are still very hidden and are an unknown factor. We feel through the networks across Australia, with NACCHO as a peak body, and the conversations we have had, that we probably are going to see much more underutilising of GP services based on the $7 introduction. That is just a general feel across the ACCHOs across Australia, that this is going to have a bigger impact than what was first described. When we look at the current health status of our community we are at the lowest end of the margin and by not accessing GPs and by not seeking preventative health care, you are going to increase the rates of illnesses and morbidity and mortality rates will increase. So there are significant flow-on effects.

The other aspect that has not been discussed with any of this co-payment has been the potential increases in areas that are less described around the socioeconomic side of things—housing and the affordability of housing. The community across Australia has had conversations around the fact that there will be an increase in crime within the youth population in general. There was a conversation that was had with a Joe Hockey address to ACOSS members at New South Wales Parliament House earlier this year that John and I attended. The impact that this will have on the youth right across Australia, whether you are Aboriginal or not, is an unforeseen example of not a measured response to a budget cut which could see youth crime increase to pay for a GP visit. It will potentially have non-adherence to medication or prescribed medication based on the cost.

The hidden cost of going to a hospital visit for X-rays, pathologies et cetera will have an impact on the youth but also the other end of the spectrum is for the elderly. We already have elderly who are noncompliant with medications because they forgo their medications to provide food and clothing to their grandchildren, as opposed to going to a GP for their own medical problems. There is a multitude of aspects that the $7 co-payment has not revealed at this stage.

CHAIR: You have done something very powerful there in terms of connecting the impacts. We are talking about one element here, but one element in any society does not exist on its own. You articulated the interconnectedness particularly well, to tie it to homelessness and to tie it to criminal activity. The notion of finding yourself in a position where as a young person you might have to steal in order to get $7 to go to the doctor just does not seem to be an appropriate thing to happen at this time in our country, when we are such a wealthy nation. You are a peak body and you are talking about a large group of people across the nation—you referred to that a few times. What degree of consultation in the policy formation stage, before this announcement, did the federal government have with your organisation?

Mr Mohor : With AHCSA itself?

CHAIR: Yes.

Mr Mohor : Zero, apart from—

CHAIR: It is a common answer.

Mr Ryan : We were invited to participate in a teleconference with Minister Nash which took place immediately after the broad policy was announced. There was some opportunity to raise issues and that resulted in the development of a Q&A fact sheet and some clarity around the detail of the policy which was not available immediately.

CHAIR: There are two points of time there: prior to the announcement, no contact; after the announcement, a teleconference and, 'Please let us know of any problems and we'll do you a Q&A'?

Mr Ryan : Yes.

CHAIR: Do you believe that process has created good policy for the people you represent?

Mr Ryan : We would not be having this conversation if it did. I do not think it has. In terms of a demonstration of policy being enforced, this is a very good example of policy being enforced. Does that answer your question?

CHAIR: Yes. So this failure to consult is of concern. The other thing is the evidence base to inform the government's decision making about bringing in a $7 co-payment and dissolving Medicare Locals. There does not seem to have been much evidence used in the decision making. Are you aware of any evidence that they accessed?

Mr Mohor : Not to our knowledge. What we are finding across jurisdictions is that there are some pockets where there has been information or evidence used but nothing that has been substantial enough to say that there is a unified position on the fact that what you are providing or presenting is agreed upon within our sector.

Mr Ryan : I would particularly make note that one of the reasons the Aboriginal community controlled health sector arose was the lack of quality services available to Aboriginal people, the effects of racism within the institutions that existed. One of the major aspects of quality is access to services and, as far as we are aware, our significant driver has been to increase access to health services for Aboriginal people, particularly where mainstream health services do not meet those needs. I have been involved directly in the Aboriginal community controlled health sector for over 10 years now, indirectly for a further 15, and I have not heard raised once the issue of over servicing within the sector.

CHAIR: In your summary responses on page 5 you indicate concerns about the current workload for the Aboriginal and Torres Strait Islander health workforce being unsustainable because of the need to perhaps fund more. I think you said in your opening remarks that there needed to be a maintenance and an increase in funding to provide the response required to meet the need in the community. Could I invite you to speak to the health workforce issue in terms of the Aboriginal and Torres Strait Islander health workforce in particular.

Mr Mohor : In terms of AHCSA's position, we are an accredited RTO. We have just received accreditation for the next five years, so one of our major arms within the organisation is to provide Aboriginal health worker training for certificates III and IV. We provide that with the support and in consultation with our 10 NACCHO members, but we also provide a far greater opportunity for those that are sitting outside of our sector, within mainstream state and Commonwealth services, to provide training. Our focus on workforce is very much around building the sustainability of our workers within the sector they are working within. What we have had since the introduction of these cuts—and we talk further in the paper about the introduction under PM&C of getting continued funding. You need to form under ORIC to prescribe to the new funding regime. We know for a fact that the Red Cross, Uniting Care Wesley and all of the not-for-profit organisations do not have to adhere to this, but the Aboriginal organisations are seeming to have to adhere to this for continued funding.

When we look at unemployment, if you are putting further restrictions in place, we have a very good proven track record. We have received accreditation for five years and now we have to adhere to another proposed requirement to receive funding, you put at risk further unemployment. The co-payment aspect as well with unemployment I am not sure where the federal government is going in supporting a $7 co-payment for those who are unemployed, and how that is subsidised if the youth in particular get six months youth allowance and then they have to find the next six months themselves, and how they afford a $7 co-payment. When we circle around unemployment, for us and our services it is about bringing our community through, that they are employed and they are getting some skills, certificate III and IV, that they are working within the health services that we have had in existence in some areas for greater than 40 years. I am not sure why the federal government would look at making this more of a marginalised group yet again through funding constraints based on the mainstream needs of plugging the gaps in a mainstream environment.

CHAIR: And you see the current government's decision making around this area making more of a gap for your community between you and health and between your community and employment?

Mr Mohor : The ACCHO sector is very much comprehensive primary health care. So we are about providing a preventive, at the forefront, in the beginning, reducing the risks of diabetes long term, based on good healthy choices around whether it is eating or their own behaviour in terms of smoking, drinking, et cetera. The end product is a reliance on a mainstream service. Our vision is not about relying on mainstream hospitalisation and that is where you are going to end up. We are about frontline services, equipping community with the skills and the knowledge to avoid all of that. What we are seeing through funding cuts is that the preventive health approach is being cut to subsidise blowouts in mainstream because of the demand in hospital beds here in South Australia. We have ramping at Flinders Medical Centre and people being treated in corridors in the Royal Adelaide Hospital based on the reliance of health systems that have gone above and beyond with their budgets and they do not have the capacity. From a community point of view, our approach is to keep them out of hospital.

CHAIR: We are hearing it is worse than getting rid of the preventive money to prop up the acute area; it is taking it out of the preventive and getting rid of the national preventive agencies, getting rid of the funding to the states for prevention, but also directly reducing funding of the acute sector as well, pulling the funding from hospitals as well. It is a perfect storm of chaos, being the word of the day, in terms of the healthcare sector.

Senator McLUCAS: Thank you for your submission. When we were in Victoria some time ago we met with VACCHO down there and it was early days in the GP tax discussion. VACCHO said to us that they had had preliminary conversations with a lot of their Aboriginal medical services and their preliminary view was that it was not possible to put a $7 charge on a person attending an Aboriginal medical service simply because of the deterrent to not come. It is hard enough to get to people to come on a regular and routine basis and to say now that you have to put $7 upfront, it would be a deterrent to patients. I asked whether they agreed with that. Then they started talking about what that meant for the operation of the business of the medical service. Given it is some time since we had that conversation with VACCHO, it would be really good to have that conversation with you today.

Mr Mohor : The best answer is that I know what VACCHO has said because I was in the same room when that was described and we were actually having that discussion. Winnunga were there as well. The description around what that meant for some of those services—and I will not describe who they are—was that they would need a minimum of 36 hospital beds to cater for a $7 co-payment for Aboriginal clients. We are talking about a comprehensive primary healthcare service with GP clinics. They would need to actually introduce 36 hospital beds to attract other Medicare moneys to keep that service going. That was one description of that particular scenario. It is a very real story.

Ms Mitchell : This issue was brought up on that teleconference with Minister Nash and some of the CEOs of the others state affiliates mentioned some of these flow-on effects to on-the-ground services. A question was asked, 'Can't the Aboriginal people who work pay the $7 and the unemployed not pay?' That would mean the services would have to do means testing, they would have to have cash on premises. Just because an Aboriginal person works does not mean they can pay this all the time. A lot of the time we are supporting other family members, extended family. There are costs that everyone has for themselves. There was quite a bit of concern about this question when it was raised. One of the CEOs said if we do not charge the $7 it could be $350,000 per year that we would have to find out of our own money to make sure that Aboriginal people come to our service. There are extra costs that are involved in seeing patients.

Senator McLUCAS: That $350,000 per year seems to be the average that we are hearing around what will happen to the cash flow frankly of an AMS. If you do not charge the $7 you lose your bulk billing incentive so it is not $7 you lose; it is $7, plus $9.10. That is the total cost per standard GP consultation that will not be coming through the cash flow of the operation of an AMS. I understand the Queensland model of AMS, but I would never try and presume to understand South Australia. It is a pretty tight operation is my judgment.

Mr Ryan : Very.

Senator McLUCAS: There is no extra cash in this Aboriginal medical service system and to lose $9.10 plus $7, or it is actually $5, for each standard consultation is untenable.

Ms Mitchell : That is right and that is not all services because a lot of the remote services in South Australia do not a have a full-time GP. One of the programs we provide is a GP supervisor who goes out to these services so that they can have a GP registrar there. There would only be two out of 10 of our services that would have a full-time doctor.

Senator McLUCAS: That is interesting to know.

Ms Mitchell : All the rest have visiting doctors who might turn up maybe one day a month.

Mr Ryan : The economies of our sector are underpinned by core grant funding and have been for a long period of time. That funding has only generally risen by inflation over time and a number of factors have meant that the real value of that has dropped. One of those, in relation to the co-payment issue is, particularly in remote areas, the infrastructure required to collect payment has a cost and that infrastructure sometimes does not exist at all within the community. It has been raised that there are security issues with some of our members with having cash on board in remote committees where the store and the clinic are the only two mainstream institutions.

Also, adding to that, Medicare has been promoted by the Commonwealth as our means of growth. This has impacts both with the reduction of the co-payment but also upon our ability to establish and run services the way that we think the community needs. By relying increasingly on Medicare we are forced to focus on throughput, particularly when—and I reflect on the comments around GP engagement of the previous witness—the cost of employing GPs is growing in a far more rapid manner than our funding ever has. The proportion of costs out of grants that that causes to be spent on GPs increases and reduces our ability to provide the comprehensive primary health care, including the employment of Aboriginal health workers who are a vital component of our sector, as well as other allied health professionals. We are losing that flexibility that comes with being nominally independent organisations and it puts a strain on us responding to community needs through that feature.

We note that there is a review being undertaken by the Department of Health of funding for the Aboriginal community controlled sector. There has been some engagement prior to this government coming in last year through KPMG. That seems to have sat on hold. We have not had any further responses or any consideration or discussion on how this current government is looking at that process. We have just been told that there will be an announcement towards the end of this year of what will be happening with that funding review.

Given that we now only have funding until the end of this financial year—we only received 12 months funding in the last budget round—we are at the end of our three-year funding cycle. We now have to live through the uncertainty of where we are going to be in less than 12 months.

Senator McLUCAS: Thank you for putting that on the record. We will follow up that KPMG review. Mr Ryan, you actually pre-empted my next question, which is great. The department says that you have all this operational money, given as an AMS, and why do you not go down the path of getting more chronic-disease management-items that you can attach to a patient? But you have answered that. You want to establish and run your services the way your community wants them to be run. You do not want to be driven by Medicare, chronic-disease management, two podiatrists and three of these and whatever that is. The other answer is perfect. If you only have one doctor going into a very remote service once a month you cannot run CDN. It is frankly impossible.

Mr Ryan : I made the point previously about the cost of recruiting GPs. Many of our services require the development of packages of income, for the doctors, which in some cases is tied to Medicare income. I do have the experience of overhearing a GP, returning from leave, complaining about the locum GP—who I know had worked in the Northern Territory, in our sector—and insisting on taking the minimum half-hour consultation times. The comment from the GP was that you cannot get enough people through to make your money. That highlights the issue that we face with ensuring adequate resourcing and the ability to provide services that we feel will address the issues around the health disparity between the communities we serve and the mainstream population.

Ms Mitchell : With those visiting GPs, they claim the Medicare but they claim it themselves. It does not go to the health service. It is only the health services that provide the salary for the GP that can get the benefits from Medicare. It is still not going back into the health service.

Senator McLUCAS: I think the department's view was that you would then renegotiate the salary if they were receiving more money through Medicare, to be fair to what the department was saying. It is a very throwaway line from the department to say, 'Just get more money through Medicare.'

Mr Ryan : It is a very competitive market for general practitioners.

Senator McLUCAS: If I get another chance I will come back, as I have another issue I would like to talk about.

Mr Ryan : If we had adequate funding to salary medical officers we would, most of our services would.

Senator CAMERON: I am not sure if you heard the previous witness, Professor Jones, who was in earlier. He put the proposition that medical care should not just be centred around a doctor, that there should be a wider group that provide that medical care. Is that an option for providing better and wider care to the Aboriginal communities?

Mr Mohor : The Aboriginal Community Controlled Health Services is based on comprehensive primary health care. It is very much comprehensive primary health care. The last resort is to see a GP. You have your Aboriginal health workers as your frontline port of call. They are then referring to—within this stage we are looking at certainly promoting Aboriginal health worker practitioners. They would be referred to an Aboriginal health worker practitioner and then onto a nursing person and then however the referral process can take. If it can be resolved within those first, early stages of client contact, certainly, but the referral process would take place however the service is set up.

It is very much comprehensive primary health care doing all of the health work. We have a technical system within our health services called Communicare that provides a recalling system when clients are due to come back and have their renal check-ups, their diabetes check-ups et cetera. The systems and technical abilities are all there. AHCSA and AMSANT, our counterpart in the Northern Territory, have spent the last three years working through a patient controlled electronic health record. South Australia is live and ready to go, but we have been told by the federal government to hold off because the federal government had not got their own backyard sorted out yet. So we have electronic health systems with discharge summaries ready to go and patient records ready to go. Through NEHTA and investment through PCHR through the Northern Territory we have been in that space for the last four years. Technically we are live and ready to go from a community and functionality perspective. We are waiting for a lot of mainstream state and Commonwealth government departments to get their backyards in order.

We have been delivering the care for the last 40 years in our communities—with very good outcomes. Through the department of health we had OCHREStreams reporting that extracted data from Communicare that sent of all the primary healthcare data—diabetes, renal, cardiac, morbidity, mortality rates for the community et cetera. That was all fed through the OCHREStreams reporting tool that was set up. Once again, that is gone. That was dissolved about 18 months ago. So the systems have been there and in place. The Aboriginal and community controlled services have been in place providing these services for a long period of time, but we are swinging and moving with the way the government funding works. We are held accountable because prior to that we also had to go through a risk assessment process that determined what our funding would be and our services would go through the same process to determine what the funding would be for the next one to three years. If it was a high risk, they would only get one year funding. So the services have been jumping through hoops with government protocol for a long period of time but to this day are still providing quality health care on the ground.

Senator CAMERON: Is your funding provided through the Senator Scullion's portfolio?

Mr Mohor : No. It was OATSIH.

Mr Ryan : Indigenous and rural health services division. We come under the Indigenous health funding peak bodies. They have created a new funding stream in this financial year. Previously we have been funded under the core funding for Aboriginal health services, although our RTO is now facing a scenario where funding for two of its major income streams—the supplementary recurrent allowance and the away from base funding streams—have now been moved to within PM&C Indigenous affairs. The issue Shane mentioned previously around the incorporation requirements will be affecting our organisation because that amounts to over $500,000 per year. An incorporated association that has been around for 20 years now has to consider its options as to how it establishes itself as an entity.

Mr Mohor : And our RTO on average for the last four years has graduated in certificate III and IV and certificate IV in a capacity research program over 150 students per year. We are now having to go through another hoop-jumping exercise for the education and training thing to register—

CHAIR: What were you saying about the $500,000?

Mr Ryan : With the Indigenous Advancement Strategy under which that funding for the RTO now comes, the funding guidelines state that, for an organisation to receive more than $500,000 in any year, they must be incorporated under Commonwealth legislation—the Corporations Act—or, if they are an Indigenous organisation, they must be incorporated under the Commonwealth Aboriginal and Torres Strait Islander Corporations Act. One of the issues—and we do make mention of it in the submission—is that, considering that we are not given the option to choose the Corporations Act, we are only given one option, and that is to come under the CATSI Act regime. 'Regime' is a word we use; we feel it can have significant issues for the regulator to involve itself in an organisation that does not exist for non-Indigenous organisations.

Senator McLUCAS: And that is around the level of auditing, isn't it?

Mr Ryan : Yes, and the ability to take over, appoint administrators, require documents—there are a number of aspects of the incorporations act that are not required of non-Indigenous organisations. That goes to the heart of how sometimes we feel that the public service perceives our sector. We acknowledge that we are not perfect. We have services that do have issues, but we think they are generally isolated instances. We do not think the entire sector should be tarred with the same brush, and we should be allowed to operate as any association or incorporation in the country should be allowed to operate.

Ms Mitchell : Especially when all had to go through accreditation in the last six to eight years to be eligible for Commonwealth funding. There are also these risk assessments that Shane mentioned that affected whether you got the 3-month to 12-month funding. There is a proven record that we can do this really well in our sector, including governance. There was a governance project that was given funding through the Department of Health and Ageing at the time through NACCHO, and we provided governance support to our members. They have been supported and they have the ability and a proven track record, so now there is just another hoop to jump through.

Senator WRIGHT: Thank you for coming along. I know the good work you do, but it is really good to have your expertise and insights into this unique aspect of the sector. In listening to what you have to say, one of the things that strikes me is how well you understand your own sector. That is not surprising, but the gap we are hearing about today is that there was not consultation. It seems like the changes to this scheme are things that have been imposed and people do not get it. They have no idea how this could possibly be implemented, and we are hearing that it really would be quite impossible. So I am imagining ACCHO is in remote areas and I think everybody agrees that, if we are going to close the gap, the idea is getting people the assistance and support they need in terms of health outcomes and other things. The idea is to get people to come have that assistance. Indeed, we are hearing about a situation where it might be that people need to be ultimately turned away because they have not got their $7 with them. I am thinking about how that then translates to children. The parent does not have the $7, so the doctor or whoever is going to be working with them has to say, 'No, you can't come'? It beggars belief that anyone could think that was a good idea or that that could somehow work. That is what I am hearing.

Ms Mitchell : In the last few years we have heard in regional places that, because of a particular monopoly of doctors in the town, someone is turned away—and this is not an Aboriginal community controlled health service—because they might have owed money. 'You've got a $15 debt? Then you can't see the doctor today.' That has happened now, so just imagine what could happen in the future.

Senator WRIGHT: And that situation is where there is not bulk billing available, obviously.

Ms Mitchell : Yes.

Mr Mohor : But the real example is also at the Royal Adelaide Hospital. There are men and women being turned away from accident and emergency because they have outstanding bills already with the department, whether they are pharmacy bills or other, from when they have been an in-patient. They have been turned away from emergency departments. So it is already happening. The turn away of $7 co-payment, whether it is a mum and two children—it could be a mum who has got on the bus to come in from the northern suburbs to the service with her three kids. To get there and be turned away is already happening.

Mr Ryan : In the teleconference around the co-payment issue it was strongly reported from our sector that we would take the hit—that services would rather not charge the co-payment and would take the hit and deal with those consequences.

Senator WRIGHT: There are a couple other questions that come from that, but I take you back to the evidence that we heard today from Mr Seiboth, who is the CEO of the Hills Medicare local and was reflecting on the fact that, through working within that community on the Closing the Gap strategy, they are starting to see some encouraging results of Aboriginal people who are more likely to go to specialist follow-ups and specialist appointments and are more likely to have their scripts being filled. There is forward progression and momentum happening, reducing the gap, and he was predicting that this was going to be totally counterproductive. They may well be Aboriginal people who are not going to an ACCHO but are going to a GP or using the more mainstream service. So the prediction is that they are going to start going back the other way. I think that is what you have been saying in your evidence today.

I take you to one of the other things you said in your summary of responses. The mainstreaming of funding has not been shown to add improvements in Aboriginal health status. You refer to significant changes in funding arrangements from the department of health to Prime Minister and cabinet. Do you want to reflect on trends on mainstreaming and taking power and resources away from uniquely culturally appropriate Aboriginal organisations and what the effects of that will also be on things like closing the gap on health?

Mr Mohor : I will paint a scenario. Medicare locals were perceived to have been the one-stop shop—comprehensive primary healthcare access. The ACCHO sector has been in existence for 40 years. These guys have only been in existence for four years. So the ACCHO sector for that period of time was not quite understanding why the new kids on the block were getting this money when we have already been in existence for quite a long period of time. For our sector in particular, if it is working, meeting the targets and starting to have some decreases in some alarming statistics that have been around for the last 20 years, wouldn't the investment be better placed going into the ACCHO sector and building around that?

We know that in some of the country regions and also the remote areas we have non-Aboriginal people accessing the ACCHO sector because they know they are going to get a better quality of care. The evidence is starting to already shape your question around the mainstreaming of services and whether they are better placed with ACCHO or a Medicare local. Once again, the Medicare locals have been reshaped into a primary health network. We do not know exactly what that is going to be; but, once again, the conversations with the ACCHO sector still have not been had. 'How is your sector going? What is that going to mean? Have the funders had those conversations with the peak bodies et cetera to see what it's going to look like in the new world?' I think we need to have those discussions. Is the government prepared to look at its own funding models to see what outcomes they want to achieve as opposed to reinventing something about which we are not sure what it will look like?

What the ACCHO sector is not about is competing. We are not about fighting each other for small amounts of money. That is not what the game is. It is about reducing poor health status and increasing quality of health care.

Mr Ryan : You highlighted the comment around the changes of funding arrangements and so on. To go back to the model of comprehensive primary health care, I refer you to the definition that NACCHO have on their website. Included in that are social and emotional wellbeing, alcohol and other drugs, substance misuse services, counselling and so on. What we have seen with the restructure of the Department of the Prime Minister and Cabinet and Indigenous affairs is the removal of a number of programs from Department of Health to PM&C. We have seen services lose programs during the period of transition. We negotiate our annual funding agreements with the Department of Health. They have been going through some restructure; as I mentioned before, we now have a new stream that we get funded by. We now also have to pay attention to applying for funding through the Indigenous Advancement Strategy, which is a competitive grant round, and we are now going up against the big NGOs. We are going up against mainstream organisations, so we are having to spend a lot of effort and time addressing this funding requirement.

Our member services are probably far less resourced that we are, because they are service deliverers and we are a peak body. They are having to take the resources away from their core business to address these issues around new funding streams and new ideas about making it simpler and reducing the burden of red tape. So far I am yet to see the benefits for member services in the new approach to funding, particularly around the areas of social and emotional wellbeing and drug and alcohol services.

Senator WRIGHT: Which are the very services which make these organisations so culturally appropriate, in that they take that holistic view.

Mr Ryan : Absolutely.

Senator CAMERON: Ms Mitchell, you gave some indication of your discussions with Senator Nash. Did Senator Nash raise with you the issue of balancing health funding against bringing the budget into balance?

Ms Mitchell : I do not think there was any mention of that. Or even of the landscape of how the IAS was going to look as well. I think it was, 'No, you have to accept it.'

Mr Ryan : It was in the early days that I spoke to her. I must admit, Minister Nash did make every effort to say that her office was open to discussion and further contact. The discussion was centred around the co-payment issue and the impacts. There was the initial teleconference, there was a further teleconference around the establishment of the Q&A fact sheets and bringing some more detail to the table, but to my awareness there has not been further follow-up of that. My memory would not be over every detail of that conversation, but it may have been raised that, 'We have to fix the budget,' but it was not a central tenet of the conversation.

Ms Mitchell : And these meetings were called by the CEOs of each state affiliate as well. We just wanted to advocate for the sector, so we instigated that teleconference and those meetings.

Senator CAMERON: I was just wondering, because when Senator Nash is asked about these issues in question time in the Senate it is either—at the start—about bringing the budget back into balance or—at the end—it is bringing the budget back into balance. That is the only response that we get. So I was just wondering whether there is one argument in the Senate and another argument elsewhere when she is dealing with the people who are having to face the consequences.

You did indicate some of the issues that you face. But given the low-socioeconomic background of many Indigenous Australians, Senator Nash basically argued that if you are in a job, no matter how low paid the job is, you should make a contribution. Was that the argument?

Ms Mitchell : Yes.

Senator CAMERON: Yes. So the other circumstances that you indicated—if you help an extended family, if you had other commitments—they did not matter; you just paid the $7?

Ms Mitchell : Yes, that is right.

Senator CAMERON: In how many area is there bulk-billing available in South Australia for Indigenous people?

Ms Mitchell : I am not sure. Do you—

Mr Ryan : All 10 of our primary medical services—when they do have access to GPs. Our membership is widely varied. We have large services, such as the one based here in Adelaide—down the road at Wakefield Street, Nunkuwarrin Yunti. We have Port Lincoln, which is 20 years old; we have Pika Wiya, which transitioned from state to community control three years ago; and Ceduna, which will have 60 employees. Some of those have better doctor access than others, but all of our services bulk-bill.

Senator CAMERON: Okay.

Ms Mitchell : Are you talking about areas such as the Riverland or areas without Aboriginal-controlled health services? In the Riverland, for instance, I know there is a huge problem of Aboriginal people being able to access GPs. At one stage there a bus would pull up outside a GP service so that people could access a GP and then try to access the CTG money so that they could get cheaper scripts. We have a worker with us through the CTG program who can provide that support to pharmacists to say, 'This is what the program is about.' But apart from that, I do not know where else across the state that is. That is something we could find out further for you, if you like—to see areas without Aboriginal controlled health services.

Senator CAMERON: Yes, it would be interesting to see what the implications are for people's standard of living, really, if they have to pay the $7.

Mr Mohor : An indication for Port Lincoln Aboriginal Health Service, which is across the Gulf here, is that a lot of the local people who are living in Port Lincoln access Port Lincoln Aboriginal Health Service versus going to a local GP, because of the bulk-billing.

Senator CAMERON: So you say that is non-Indigenous as well, do you?

Mr Mohor : Yes. A large proportion are accessing that because of the bulk-billing aspects of the service.

Senator CAMERON: Just going back to this issue of your funding: do you have any indications as to when that decision will be made on your funding?

Mr Ryan : There was a Q&A sheet that indicates it will be in the latter half of this year.

Senator CAMERON: The latter half of this year.

Mr Ryan : This calendar year.

Senator CAMERON: So it goes to 2015, does it?

Mr Ryan : Yes.

Ms Mitchell : We did not get the funding agreement for this financial year until 29 June.

Senator CAMERON: Okay. It seems to be a bit of a pattern that if the government is not going to fund, it creates this uncertainty so that you lose your core people who have access to other employment. And then even if they say that the funding is there, then you have lost your capacity to deliver. Is that a problem to you guys?

Mr Mohor : Ongoing. Every year it is ongoing. The issue around the funding is definitely described as December for some programs. The National Tobacco Program that Tom Calma is reviewing through Canberra at the moment: we have been told that December is how long the contract will go for, even though it is until 30 June 2016. There is no guarantee beyond 31 December this year. At best, you could be looking at funding to March next year. That was an indicative comment that was made, based on the whole-of-Commonwealth funding for health programs.

Senator CAMERON: In terms of the lack of funding and the general cuts that are in the budget, which you will end up being part of if that is the negative outcome: you are arguing that it has negative impacts for the health of Aboriginal communities, that it is going to have negative impacts for the social cohesion of Aboriginal communities and there could even be deaths arising from lack of medical capacity. Would that be a problem?

Mr Mohor : Yes. It is a significant problem. One income earner could be one income earner for two or three families in some areas within the communities. And for studying: somebody doing health worker training could be the first person in that whole genealogy of community to do a certificate III in Aboriginal health worker training and there is no job to go at the end of it. There are bigger implications than just a $7 co-payment. There are significant socioeconomic issues, there are significant housing issues in terms of affordability of housing. If you take away a main income earner, you take away, potentially, the reliance on paying rent, or being in a housing trust home or whatever accommodation they are in. But we are also talking about medications, food, clothing and kids going to school. So the whole family construct is being pulled away based on an imposition of seven dollars, which is—as we have already described—an unknown, because you do not know how deep that $7 is going to go. If a child has a chest infection, they need X-rays but they also need medication. But we have just found that they have asthma, so they need regular puffers—the list goes on. So there is a $7 addition all the way through. In the demographic environment we are going to see death as the worst case scenario—

Senator CAMERON: Because people do not access?

Mr Mohor : People do not access regular medications. You could have elderly people who are not accessing regular diabetes or high blood pressure medications, so they put themselves at risk. Demographically, we are going to see the stats turn back upwards where they are on a significant growth upwards.

Senator CAMERON: Thank you very much.

CHAIR: Thanks for coming in—for the work you do and for spending time with us this afternoon, helping us to understand the issues that you confront daily much better.

Mr Ryan : Can I just make one point? In the submission that we provided you there are two sections: our responses to the terms of reference and also attached is what we call our 'AHCSA investment paper'. It is a paper we developed for both parties prior to the state election here in South Australia. It outlines the case for why we think investing in Aboriginal community control makes economic and quality sense in improving health outcomes.

CHAIR: Thank you. It is very nice to hear that 'quality' word; it is not just all about money.

Mr Ryan : Thank you very much.