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

COUSINS, Mr Michael, Manager, Policy and Advisory, Health Consumers Alliance of South Australia

MILLER, Ms Stephanie Faith, Executive Director, Health Consumers Alliance of South Australia

WHITEWAY, Mrs Lyn, Consumer Advocate, Health Consumers Alliance of South Australia


CHAIR: I now welcome Ms Stephanie Miller, Mr Michael Cousins and Mrs Lyn Whiteway from the Health Consumers Alliance

of South Australia. Thank you for joining us. I invite you to make a brief opening statement and then the committee will have questions.

Ms Miller : Thank you for the opportunity to come to talk to you today. I will say a few brief words of introduction and then I want to hand over to Lyn to share her story with you briefly, if that is okay.

The Health Consumers Alliance of South Australia believes that a safe, quality and efficient health system is one designed around the patient, with respect for a person's preferences, values and needs. That is, one that is consumer centred. There is good evidence that a reorientation of health services to a consumer focus can deliver measurable improvements in safety, quality and health outcomes, efficiencies and better consumer experience of care.

Through the engagement work we have done with our members and also with the broader community we know that consumers what a health system that promotes health and wellbeing, that recognises our rights and that treats us as whole people with emotional, social and physical needs. Healthcare providers and practitioners are the visitors in our lives. The engagement of consumers as full and equal partners in our own care, as well as designing and implementing change in accordance with the principle 'nothing about us without us close', is a core principle that we believe in.

HCA also believes that Australian governments should continue to seek to improve our health system, based on evidence and informed by a social view of health. In a wealthy country such as Australia we should be seeking to reduce health inequalities, improve access to health and social services and improve the safety and quality of our health system. We are very concerned about the current discourse focused on the financial sustainability of the current health system and the view that health is an individual responsibility without any social determinants or societal value. The proponents of these views put forward very little analysis or evidence about how such proposals will improve the health of Australians. This may be because the actual weight of evidence favours universal health care and access, and a population health approach.

At the same time, however, we do not necessarily believe that increasing funding is the answer either. There is significant duplication and inefficiency in our system and that absolutely has to be dealt with and confronted. There is strong evidence, in fact, that higher spending on health care does not necessarily deliver better health outcomes. The triple aim framework developed by the Institute for Healthcare Improvement identifies an approach to optimising health system performance focused on simultaneously pursuing three dimensions. They are: improving the consumer experience of care, improving the health of populations and reducing the per capita cost of health care. Those three dimensions are linked systemically and work together, and need to be focused on as a whole.

Unfortunately, the health initiatives proposed in the 2014 Commonwealth budget do not appear to meaningfully address any of these dimensions for healthcare improvement. In South Australia our health system is already struggling to keep up, as I am sure you have heard some evidence about today. Further cuts will be absolutely devastating. While by many indicators you could argue that we have a world-leading health system in Australia and also in South Australia, consumer experience survey and complaints data actually tell a somewhat different story. We acknowledge that there has been significant work done over the past few years on learning from and making improvements based on consumer feedback, and we congratulate SA Health and others on that work.

The good news is that there is a trend in the right direction, so we are making progress. However, we think that we are at real risk of reversing that positive trend in improving consumer experience. We have invited Mrs Lyn Whiteway here today as one of our health consumer advocates and a member of HCA to share some of her recent experiences with you.

Mrs Whiteway : I am an age pensioner, I have a chronic illness, and I also suffer from chronic pain. My husband is my carer. I have private health insurance because, unfortunately, I cannot rely on the public health system, and here is an example why. On 1 May this year, I was so ill that my husband called an ambulance. I went to a major public hospital because I could not afford to pay the $400 fee to go to a private clinic at Wakefield Street. Despite being on an age pension, they do not give any discounts for age, unfortunately, so I elected to go to a major public hospital. I was suffering from excruciating pain in my back and left leg. I could not put my leg to the ground, I had a very high temperature and I just could not walk. When I got to the hospital I was seen fairly quickly. I had a chest x-ray, a blood test, a urine test and I was seen by two interns—who looked like babies to me; they were very young. I did not ever see a senior consultant.

I was sent home after two or three hours, even though I had to be wheelchaired to the exit because I could not walk. They did not listen to me when I protested that I felt so sick, that I could not walk, and when I said, 'Please put me in a wheelchair'. My husband took me straight to IGP, who prescribed antibiotics with instructions to check back within 24 hours or earlier if my condition deteriorated. After 24 hours I went back to my GP and, yes, I had deteriorated quite badly. He immediately admitted me to a private hospital under the care of two specialists. I had x-rays and unltrasounds done, a CT scan and blood tests. I was diagnosed with a staph infection, septicaemia and an epidural abscess. I had a PICC line put in and two IV antibiotics and pain management administered. I was extremely ill for the first three weeks of my 3½-week stay in the hospital. I had temperatures of 39.5-plus, and I remember icebags being put on my head to reduce my temperature, because I was hallucinating.

My GP and the two specialists who looked after me all told me at different times that I was lucky to be alive and that, had I been admitted to hospital 24 hours later, I would be dead. I am still on large doses of antibiotics five months later and will be taking them for at least another five months, maybe more, due to the severity and the spread of the infection in my spine. I am seeing an infection specialist every four weeks, and I have to pay a gap of $40 each time I see him.

I need surgery on my cervical spine. I have great troubles with my right arm because of a nerve being trapped, and it affects my quality of life. I cannot hold my four-month-old granddaughter in my arms or pick up my two-year-old grandson for long. I drop things and I am in pain. I was due to book in with a neurosurgeon for surgery privately, but we cannot proceed at the moment due to the risk of infection.

I feel let down by the public system. How did they miss obvious serious illness? Why wasn't I investigated further? At no time did I see a senior consultant. I have tried using the complaints process within the public hospital. I wrote them a letter and I did get a letter back, but there was no apology in it.

The good things to come out of this whole debacle are that, No. 1, I am still alive; I have good private health insurance which covers all of my hospital stay, the ambulances, the hospital room and the specialists whilst I was in hospital; and the nurses in the private hospital were fantastic. My GP bulk-bills. I have reached the PBS safety net and my drugs are free at the moment.

I am concerned about the impact of proposed funding cuts to the hospital system and how that will impact an already stretched public health system, because I believe it was purely monetary that I did not get to see somebody more senior. The staff were stretched to their capacity; there were not enough doctors on. I do not really know the answer, but obviously there was a problem somewhere. I understand that no system is perfect, but I would like to think that our public health system would be there if I needed it and that I would not have to rely on my private health insurance to save my life.

I am also concerned about the proposed co-payments for GPs and pathology and how that may affect my ability to afford health care. I use the health system a lot, so I think I would be in dire straits. My budget is already stretched to the limit. I would just like to thank you for the opportunity to share my story.

CHAIR: Thank you, Mrs Whiteway. It is delightful to see you have this great sense of humour after the journey that you have been on. We heard this morning that there are 290,000 more presentations likely to happen at South Australian hospital emergency departments if the $7 GP co-payment goes ahead. One of the problems that have been articulated in evidence in the last couple of days is that, with that many more people at those emergency departments, not only would there be more of the experience you have had, where you said there was stress in the system already, but the people who were there training would be almost unable to be trained because the need to push people through would be so profound that it would no longer really be a place to do adequate emergency medicine or to train another generation. So you have described the heart of a pretty serious problem.

Senator McLUCAS: I also appreciate your story being shared with us, and I was going to go to exactly those two points. You were identifying that alternative treatment could have changed the trajectory of your treatment. If you have another 270,000 people coming through those emergency departments, your experience will not be better. You were sharing the time you had with a lot more people. I would be interested in any of your comments around why that happens. Essentially, the South Australian government, along with the New South Wales government, have similar data. They are saying that the imposition of a GP co-payment is the driver for this growth in attendances at emergency departments, and it is not just because you wake up with a sore throat and you think: 'I've got to go to the doctor. I won't go to my GP, because I'll have to pay; I'll go to the emergency department.' It is more the delayed attendances that then compound into other things. I think there has been a bit of a misunderstanding, particularly in some of our media, around what this attendance at emergency might be. The secondary question, of course, is about the extra $7 payment. Do you want to make any comments around those questions?

Mr Cousins : I think a key aspect of Lyn's story is that this occurred at the start of May, so even before the Commonwealth budget was brought down. So we are already seeing a health system struggling. It was not winter yet, so it was not at the peak of emergency department presentations, and it is not an isolated story. Lyn's story is one that we have picked up on as being part of a pattern or a theme. A number of consumers have told us over the years about their encounters and about being sent home just with paracetamol when actually their illness was much more severe and probably should have been investigated further at emergency departments. So that is one key point about that. That could only get worse with 290,000 more presentations a year.

Another theme or aspect of ED presentations that is getting some media in South Australia is that of patients with a mental illness being trapped in emergency departments for a number of days—up to a week at a time. Unfortunately, because it is such an inappropriate place for somebody experiencing a psychotic illness, they are often accompanied by a security guard and far too often are being chemically and physically restrained and kept in a windowless room, which is entirely inappropriate for enhancing and leading them to a recovery—it actually worsens their symptoms.

This has happened repeatedly in South Australia over the last year and well before that. So things are not getting better for people living with mental illness, and that will just get worse if emergency departments are going to be so crowded with an influx of 290,000 new presentations.

Senator McLUCAS: Mr Cousins, I really appreciate you making that point. I would put on the record my commendation of the ABC for the programs that they are running this week during their 'Mental As' week. The program that ran last night and the night before, which is like a window into a high-involuntary admission unit in Sydney Hospital, will, I think, help Australia understand the nature of the problem that we have because a lot of that has been hidden in the past. I am going to ask a series of questions around Medicare Locals and particularly the Partners in Recovery program. If you do not want to answer them, or if they are not an area of specialty that the Health Consumers Alliance has, please just tell me that—there is no issue.

Ms Miller : We do not have a lot of specialty around Partners in Recovery but we have worked closely with Medicare Locals. If you wanted some general comments about Medicare Locals we could certainly make them.

Senator McLUCAS: Tell me what you think about the motivation for the changed timetable and what you have been hearing as health consumers around the future for the PHNs.

Ms Miller : I should say that I am on the board of the Central Adelaide and Hills Medicare Local. HCA is a member of three of the Medicare Locals in South Australia—in fact we were a founding member of two of them. So we have had quite a lot of engagement right from the beginning. We believe that Medicare Locals were making some good progress in the work that they were charged to do. In particular, our experience of working with Medicare Locals compared to what was before Medicare Locals has been much more positive in terms of our engagement with those organisations. They have had a much broader focus on population health and needs assessment and planning and they have, by and large, been much more engaging with other sectors in addition to general practice. We found that a very positive development and we believe that has led to Medicare Locals becoming much more relevant and strategic organisations from the consumer perspective. They have taken a broader population health approach and they have really engaged with a wide range of stakeholders, and that has influenced the work that they have done.

Senator McLUCAS: There has been all this commentary from Minister Dutton that in this brand new world of PHNs we are going to have 'GP led' programs. I have been around this sector since 1995 as a health consumer on a division of general practice in a rural town—a long time ago. When you construct the argument that we need to move to a GP led service that tells me that something is not GP led at the moment, in Minister Dutton's mind. But that whole argument about GP versus the world is a story that is a long time ago. That argument does not exist in my head anymore and I have called it a straw man. There is not a fight between GPs and allied health and nurses and consumers. That is something that was happening 20 years ago—if in fact it was. Is that your view? Where is South Australia in this move from GPs to primary healthcare services, including consumers and making sure it is patient centred?

Mr Cousins : I too worked in the divisions program back in the nineties, so I am very familiar with that culture and that history. I think one of the things about Medicare Locals is that they have not had enough time to really mature as organisations and to start to move into performing consistently as mature organisations. Some have and some have not. I think that needs to be said. I think the status of general practice has waxed and waned over the last 20 years, but really the role of general practice has been enhanced through changes in how Medicare is operated, in terms of new MBS items that allowed access to allied health services and access to dentistry, but that access was through the general practitioner. They were great enhancements—also, implementation of some of the learnings from the coordinated care trials, leading to health planning from general practice and enhanced care items.

GPs had opportunities to be quite strongly involved in Medicare Locals. I think the reason that we moved from divisions of general practice to Medicare Locals was that , there was a clear understanding that there was a need to engage the wider primary health sector, particularly allied health, and also to look beyond the fee-for-service model that is inherent in Medicare and general practice and to look at other ways of addressing primary health needs and primary health models and looking at population health. Doing that through fee-for-service structures is quite difficult. Had Medicare Locals been allowed to move forward and blossom and reach their full potential, we would have seen quite a dynamic primary health, population health system in Australia evolve.

We have had some great successes in the past. I think they are really at risk, particularly here in South Australia, because the state government retreated from its programs in primary health, in prevention services, because of the national agreement with the then federal government. Then we got a new government and they tore up that agreement. The workforce basically has been decimated. Talented people are not able to get jobs in their field. So it is a sorry story here in South Australia for prevention services, health promotion services and a population health approach.

Senator McLUCAS: Thanks very much. It is very sad.

Ms Miller : While we are engaging in the Primary Health Networks process and are part of discussions and trying to influence that, if they were to be GP led organisations, we believe that that would be a backward step. They should be community and population led organisations with general practice at the heart. Certainly general practice is important to consumers, and I say that as a consumer and carer myself. But, when we talk about general practice, it is not just the GP; it is also the allied health professionals, the nurses and all of the people that are part of that primary healthcare team—that really needs to be the focus of the Primary Health Networks when they are established. Certainly there is a proposal that those Primary Health Networks have consumer or community advisory committees. We have been advocating here in South Australia that they be core to the Primary Health Networks and they have a very strong influence over the continuing work.

Senator McLUCAS: As my last comment, can I say it is actually a step backwards in terms of consumer engagement compared to the board that I was a member of in 1995.

Senator WRIGHT: Thank you very much for giving up your time to come along to share your particularly unique insights into this with us. Can I take you to the preventative health field, because, as you say, in South Australia it is a particularly grim story, because we saw real cutbacks under the state government, on the basis that they were expecting that the federal government programs would continue. How does that particularly affect members of your organisation? Can you just paint us a few pictures about how the loss of some of those programs will affect either your particular members or else consumers of health services? I am thinking particularly of some programs I know in the mental health area, but you may have some others.

Ms Miller : I would like to comment on mental health, because I think it also relates to the discussion we were having about emergency departments. Yes, there has been quite a focus on people with mental illness and their experience at emergency departments, and there are a number of reasons for that. One of the reasons is that the services in the community, in terms of the stepping up and stepping down recommendations and those preventative services in primary health care, do not actually exist—or certainly there is not the capacity there. So people are ending up, as you said, delayed, and they are sicker when they get to emergency departments. If the services were there in the community to prevent people's illness escalating, and to reduce their need to go to emergency departments, that would partly alleviate the problem.

In South Australia we have had a great plan to have this stepping up, stepping down system of mental health care, but unfortunately we have not invested enough in building the capacity of the community sector. At the same time, we have taken away beds in the acute sector. The timing of how we have done that has not happened the right way around. I think there is a real gap in the area of prevention in mental health.

Senator WRIGHT: They are the recovery services often, aren't they?

Ms Miller : Yes.

Senator WRIGHT: It is not only stepping up and stepping down, which obviously are really important; it is also the maintenance of wellbeing within the community so that people do not end up, as you say, escalating into an acute situation that requires hospitalisation—and maybe sitting shackled in a windowless room for four days. If you were going to design something to make people unwell, that is exactly what you would design for them. It is really so awful and counterproductive.

Mr Cousins : Sexual health is another area that is a key example of the retreat from prevention—from health promotion and education services. We have had some good successes here in South Australia in the area of HIV-AIDS education and prevention, as well as in the area of sexual health in general with SHine SA. But their funding has been cut. The AIDS Council here no longer exists, although that has nothing to do with the federal government; it was a decision made by the state government and it was a decision with a particular history. There are still education services here in South Australia that target key groups in HIV-AIDS, but they are much reduced. We used to have a particular service, the Second Story Youth Health Service, looking at sexual health for same-sex attracted young people. That no longer exists.

There has been a retreat from youth health services in general. Those general youth health services are quite important for a whole range of reasons—sexual health being one, mental health being another. Now, if young people want to access a youth health service, they need to do so either through a local government council or head down south—it is at Marion, I think—or up north. I do not know where the northern outlet would be. But those services have been much reduced. That is very much a concern, because sexual health in young people is something there always needs to be education about. There are always new young adults starting their sexual careers. So we have to maintain a constant approach in education, health promotion and disease prevention for young people. It is quite scary where we are going to end up in this area.

Senator WRIGHT: It is self-evident that that is going to be counterproductive for social wellbeing. If we are going to be hard-headed about this and do what you warned us not to do, Ms Miller, and that is to just see this as an economic issue rather than a health issue—since this is ostensibly about a confected crisis in the health funding system and, larger than that, the so-called budget crisis—you would still ask what the ultimate economic costs will be of winding back those first-tier preventative services. What would the risks of that be?

Mr Cousins : I think we will see a transfer of costs to later years, to later governments, to later terms of parliament. There will also be a transfer of costs to individuals and families. We will see rising chronic illness and rises in communicable diseases that we could have prevented. We know that obesity, as an example, is a big problem in Australia and across the world—not just in the First World. We really do not have any plans in that area anymore. We have had some good programs, but we have not had a brilliant program that uses the Ottawa Charter for Health Promotion—that looks at changing society, addressing public policy, having health information and education, or dealing with the food industry. The food rating system was cancelled in the first weeks of the new government. It is really alarming what is happening around prevention services.

Those costs will be transferred in many ways to individuals and later generations, and we will end up with an unhealthy society and possibly end up like the Americans, who are now looking at the first generation of having a shortened life expectancy, after having a couple of centuries of enhanced life expectancy. So the next generation of Americans will have a shorter life expectancy than their parents. That could happen here.

Senator WRIGHT: What a terrible legacy. Can I ask you about rural people? I am really interested in the impacts of this particularly on rural people. We know the burden of disease is larger there and generally the incomes are lower in South Australia. Can you tell me about your country members and the impacts on them?

Ms Miller : We do have country members. In fact, HCA's deputy chair is the chair of Health Consumers of Rural and Remote Australia. So she has quite an impact on the work that we do. HCA did a piece of work a couple of years ago with SACOSS, UnitingCare Wesley Port Pirie and the Farmers Federation of South Australia. It was a medical justice project. We identified that there were some rights and injustice issues for country health consumers in terms of their access to healthcare. We did a telephone survey, and the results of that project really confirmed what the latest statistics had been from the Australian Bureau of Statistics around people delaying access to healthcare because of the impact on their budget, because they could not afford it. That is exacerbated in country because there is less access to bulk-billing services. People reported to us that, if they wanted to be able to bulk-bill, they had to travel to bulk-billing services—so that added to the cost again. The reason that this project came about was that UnitingCare Wesley Port Pirie reported that more and more clients were reporting to them for financial assistance to cover medical costs. That was a couple of years ago. I think we can safely say that things have gotten worse since then and will only get even worse if some of the Commonwealth budget changes are introduced.

So there is a disproportionate impact on country health consumers. Also, we know that people are sicker. The burden of chronic disease, access to health services, access to mental health services and support around drug and alcohol issues is very minimal around country South Australia. We say we want a health system where people can have access to healthcare when they need it—right time, right care, right place—but that is not a reality for people in country South Australia. They are having to travel to regional centres or to Adelaide to get the care that they need.

Senator CAMERON: Thanks for your submission and thank you, Mrs Whiteway, for coming along and providing your story. I must say that I am a strong supporter of the public health system, and I would not want anyone to walk away and think that Mrs Whiteway's distressing story is typical of how the public health system works—it is just not. I am a bit worried that that is one of the focuses of your submission, because it seems to me that there is a strong move with this budget to try and put more responsibility on the states and more responsibility on individuals to look after their own healthcare. If that is the case, if you do not have access to private health funding, we will go down the US system. I am sure that is not what you are advocating, and that you are a supporter of the health system and it is just really unfortunate that Mrs Whiteway has had that terrible experience. That can happen. But, for every experience like that, there are hundreds of thousands who have very beneficial experiences in the public health system. Wouldn't that be so?

Ms Miller : Absolutely. We are also strong supporters of the public health system. We do not want to give the impression that we are not. The point that we were trying to get across with Mrs Whiteway's presentation was that she unfortunately was left to rely on private health insurance to get the care that she needed, and that absolutely should not be the case for any Australian—that they have to rely on private health insurance. We believe in a universal healthcare system. We believe that people should not have to have private health insurance to get good quality, safe health care in Australia. The thing I would also like to add about the public health system is that it does bear the burden. It bears the burden of the sickest and the most ill Australians. I guess that is evident in what we are experiencing in our public health system, because there is pressure in terms of funding and all sorts of other things and also increasing demand on that system.

Senator CAMERON: We have heard some evidence that the hospital system is about $56 billion, the primary care system is about $53 billion and public health is about $2 billion. Professor Glenn Salkeld has said that this is the wrong way around. I think that is the thrust of your submission a bit as well.

Ms Miller : Yes.

Senator CAMERON: On page 3 of your submission you state that the highest spending on health care does not necessarily deliver better health outcomes. I do not think you are saying—but you can explain it—that we should not spend more on health. You are arguing about the efficiency of the health system, a bit like the example of Mrs Whiteway, and the priorities in the health system. Is that what you are arguing there?

Ms Miller : Yes. We are arguing value for money. As a consumer organisation we represent a diversity of interests in terms of consumers with different values and beliefs about health care. Taxpayers want value for money from our health system. Just throwing money at the health system without actually thinking about what the best use of that money is not going to solve the problem. It has been shown internationally that it does not solve the problem. For us it is about designing a healthcare system around the needs and preferences and values of consumers and having that triple focus on consumer experience of care; population health, which is a much broader thing than individual care and treatment, and outcomes from hospital treatment; and also reducing per capita cost. If that means that in some areas we have to spend more money and in others less and that leads to better population health outcomes and a better consumer experience of care, then that is how the system should be reoriented.

Senator CAMERON: That would not happen overnight and it certainly would not happen in the medium term. This would have to be a long-term objective.

Ms Miller : Absolutely.

Senator CAMERON: As I understand it, the system we are in now has been in place for decades in Australia. You just cannot cut off from one and move to another. What is your assessment of moving to what you see as your preferred system—they are never perfect—against where we are now? There can be a cost to that. How long would that take and how much money would you need to spend to get from one to the other to reverse the huge cost of hospitals, put a cost up-front and stop people ending up in hospital? How do you do it?

Ms Miller : We tried to do that in South Australia with the generational health review. I think that acknowledged that this is generational issue. If you are going to really turn around and reorient the health system it is a long-term thing. But that needs political courage and leadership to make some hard decisions around who makes the decisions and how they are made about our healthcare system. I guess our point of view is that we have had this system which is designed around the needs of practitioners and providers. We are not going to be able to turn that around unless we decide that we need to acknowledge that consumers are at the heart of this system, so it is nothing without us. We have kept on doing the same old thing, in terms of the patterns of power and who makes decisions. We need to say, 'Let's really put consumers at the heart of this thing; let's really partner with consumers and the community,' and have those difficult conversations with the community about how we do need to reorient, how we do need to change our priorities. No-one seems to want to really do that. For us that is one of the stumbling blocks.

Mr Cousins : If I could provide some specific examples and go back to an earlier question you had, there are a couple of key examples in South Australia where we have put more money into the existing system. What we have got back is the existing system. There are 100 million new dollars in the mental-health system in South Australia. We have some nice new buildings and infrastructure. That is great. It was overdue and long needed. But the model of care really has not changed. We have not seen a big expansion of the community based sector. We are not seeing stepping down and stepping up. We are seeing people being stuck in emergency departments. That is an example of putting more money into an existing system and getting back what the existing system provides.

There is another example. SA Health is well aware of this. We have the highest number of medical practitioners in the country, we have the highest number of nurses in the country and we have the highest number of hospital beds in the country.

Senator McLUCAS: On a per capita basis?

Mr Cousins : On a per capita basis. We should have the healthiest population in the country, perhaps. We do not. You can ameliorate that with other understandings. We have an older population. We have a population with higher levels of disability. But if you put more money into the existing system, the way it is, you will still get the same results. I think the people in SA Health are beginning to realise that and are having some serious conversations about that.

Ms Miller : Could I just clarify something? My understanding is that we have the lowest number of acute mental-health beds per capita. That is just one little thing.

Mr Cousins : An exception, yes. We also have probably the lowest proportion of mental-health money being spent in the community sector in Australia. Victoria is leading, I think. South Australia is way behind, in terms of having built its community based mental-health sector.

Medicare Locals were probably a baby step forward in reorientating the health system. It is nothing like what we really need to be looking at. There are so many dominant vested interests in our current health system that they are difficult to challenge, but we have some great examples in Australia of having done that. Look at the success of tobacco control in Australia. That is using the Ottawa Charter for Health Promotion quite thoroughly. There is reorientating health services, investing in new types of services, looking at things in an intergenerational manner, using evidence, engaging the community, engaging medical practitioners and engaging the population.

In South Australia there is a good story. We had a new health minister who came in. They needed to make some cuts. They cut back on health-promotion advertising around quitting smoking. They saw a rise in smoking rates, in South Australia, and they quickly reversed that decision. So there is some good thinking there, when we have the data sources and when we have resources to spend on effective strategies. We need to have those types of approaches across the gamut of what makes up a good primary-health system.

Senator CAMERON: I appreciate that. We do not have much time. If you want to put any more of this on the record I would be happy to hear it on notice from you, if you have some examples of where we should be going. You raised the Medicare Locals issue. I have raised, with some of the witnesses, the issue of the Horvath report and the AMA's submission to the Horvath report—you cannot put a cigarette paper between them. You look at the AMA's submission and you look at what Horvath has determined and you see what the AMA wants. That is that vested-interest approach. Is it your submission that these vested interests are not allowing small steps—like the Medicare Locals—to provide benefits, because of vested interests? Is that the proposition you are putting to us?

Ms Miller : That is certainly one of our concerns, I guess, who has influence on decision makers. There are strong and powerful vested interests. Consumer organisations like ours and Consumers Health Forum of Australia have difficulty being heard in some of those debates. That is just one example. I think the decision about Medicare Locals and the Horvath report are an example of the power and influence of those vested interests. In South Australia, we have a system that is not a 24/7 health system, so there are industrial issues in South Australia that need to be tackled around how our health system is designed so that we can actually have doctors working 24/7. That will help to deal with some of the backlog in our public hospitals, because people are not being discharged and people like Lyn are seeing junior doctors rather than senior consultants. So there are a lot of examples of where those vested interests are putting up smokescreens or barriers to fundamental change in the system, which is really about a paradigm shift at the end of the day. We are talking about a paradigm shift. We are talking about changing the culture, moving away from silos and having a strong, team-based approach, which includes partnership with consumers.

Senator CAMERON: But given the nature of our system here, with the vested interests such as highly paid and highly skilled consultants, do you see them working night shifts? How is that going to work, other than by increasing the supply of specialists into the system? That is a cost. You increase the supply so that you can give that coverage. But, if you are reliant on a small core of highly skilled, super-paid professionals, they are not going to work night shift, I would think.

Ms Miller : Yes. I guess there are other options about changing the workforce, so changing scope of practice for other professions. Allowing nurses and junior doctors to discharge is just one example—maybe introducing other professions. Those were the sorts of issues that Health Workforce Australia were working on, and that is another example of an agency that has been abolished.

Senator CAMERON: So that is not so much an industrial matter as a professional matter.

Ms Miller : Some might say scope of practice is, but I am not an expert on industrial relations.

Senator CAMERON: Okay, that is fine. Thanks very much.

CHAIR: Thank you very much. It has been fantastic to have you come and give us your perspectives today. Can I just ask if the Health Consumers' Alliance national body or you as a representative of an entire state were consulted in the lead-up to the budget announcements around health cuts.

Ms Miller : The Health Consumers' Alliance of South Australia certainly was not consulted. I cannot speak for the Consumers Health Forum of Australia.

Mr Cousins : I am not aware that they were.

Ms Miller : No, we are not aware that they were.

CHAIR: We are discerning a pattern that there were many people who had zero consultation.

Ms Miller : Yes, I think that is probably—

CHAIR: And it would seem to be that that is the case for you as well.

Ms Miller : Yes, I would agree.

CHAIR: Since the announcement of the budget, how would you characterise the consultation between your organisation and the federal government?

Ms Miller : It has been challenging. We, as part of the SA Health Alliance, have been campaigning against the Commonwealth budget measures, and we have been to Canberra a couple of times. It has been difficult to get a hearing with representatives of this government, especially with the minister. So it has certainly been challenging, and I would certainly say that we are still not being heard.

CHAIR: Have you had any meetings?

Senator CAMERON: What about local members and senators?

Ms Miller : Yes, we have had meetings with senators and local members—South Australian senators, including Senator Penny Wright and Nick Xenophon. I have another meeting with Senator Xenophon next week on behalf of another organisation.

CHAIR: What about the member for Sturt, the member for Boothby, the member for—

Senator CAMERON: The coalition?

Ms Miller : No.

Senator CAMERON: No coalition? Have you approached any of the coalition members?

Ms Miller : The SA Health Alliance met with Senator Nash in Canberra and recently also with Senator Fawcett.

Senator CAMERON: I have been very critical of the South Australian coalition members. I just think they are weak kneed and jelly backed. They will not take a position—

CHAIR: They are two of the senator's favourite expressions!

Senator CAMERON: in support of their communities, and they just run the party line. And they do not even come here to hear the issues you are raising and the challenges for people like Mrs Whiteway. They do not turn up. There is more than one way to skin a cat with the government, and I think the pressure has to be put on these local members who just toe the party line and do not seem to care or are too frightened to stand up for their own communities.

Ms Miller : In our meeting with Senator Nash in Canberra as part of the SA health alliance we presented to her some arguments about the importance of universal health care and positive health reform, which she kind of half agreed with, but her main position was that in our communities we used to look after each other, so we need to be doing more of that and not relying on government to look after us.

Senator CAMERON: Did she give you any explanation of how you would do that?

Ms Miller : No.

Senator McLUCAS: So, my neighbour would do my brain surgery—fantastic! I look forward to that event!

CHAIR: We had bit of evidence to the effect of what it was like in the good old days—which, under a bit of scrutiny, are often the bad old days—when we had Professor Duckett describe his first job in health as basically a debt collector, in the pre-Medicare days, going around and collecting money, garnishing people's wages for the debts they had incurred in seeking urgent medical care. Australians today, many of whom have been born since that time, have no concept that such a time existed: back to the future, the 1950s with Father Knows Best. I do not know, but I do not think we are in quite the same place anymore, and I do not know that it was that good.

Senator WRIGHT: And Senator McLucas, I would like to buy a ticket to that event—neighbourhood brain surgery! But it does interest me: I think rich people will still be able to pay to have brain surgeons do that sort of work. I think it is maybe just the poor who need to go back to the good old days.

Mr Cousins : Following on from the chair's comment, a couple of years ago I attended a Consumer Health Forum of Australia workshop on informed financial consent for health and medical care, and there we heard stories of people putting their family home up for sale so that they could fund particular surgeries or treatments—a whole lot of horror stories that I just did not think would exist in contemporary Australia, but they do exist, because access to care is not as universal as it can be. Australia has the second-highest level of out-of-pocket expenses for medical care in the OECD, I think, so we can improve the system, and I think we should.

CHAIR: We probably do not need to send price signals of 'Don't go to your GP' then.

Mr Cousins : No, definitely not.

CHAIR: Thank you very much for your evidence this afternoon. Thank you also to Hansard, Broadcasting and the secretariat for their work in preparation and throughout the day. That concludes today's public hearing.

Committee adjourned at 15 : 33