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Standing Committee on Health
01/10/2015
Chronic disease prevention and management in primary health care

BOOTH, Ms Karen, President, Australian Primary Health Care Nurses Association

GIBBS, Ms Colleen, Senior Policy and Research Officer, Congress of Aboriginal and Torres Strait Islander Nurses and Midwives

GRANT, Dr Julian, President, Maternal, Child and Family Health Nurses Australia

McLAUGHLIN, Ms Kathleen, Acting Chief Executive Officer, Australian College of Nursing

RYAN, Ms Kim, Chief Executive Officer, Australian College of Mental Health Nurses

[13:37]

CHAIR: I now welcome representatives of the nursing groups. Do you, as witnesses appearing before the committee, have any objection to being recorded by media during your participation in this hearing?

Ms McLaughlin : No, we do not.

CHAIR: I take it you have read the card in front of you with regard to parliamentary privilege?

Ms McLaughlin : Yes.

CHAIR: I now invite you to make a short opening statement to the committee.

Ms McLaughlin : Given that there are five of us here today, we are all going to present a very short statement. They will be limited to two minutes each. I start by recognising the traditional owners of the land on which we are meeting and pay respects to elders past and present. Thank you for the opportunity to attend this hearing today. Today you will hear from the key nursing bodies before you that represent nurses working in primary health care across Australia and across a range of key areas of practice. My colleagues and I will each present a two-minute statement highlighting key points for your consideration.

I am the Acting Chief Executive Officer of the Australian College of Nursing, the national professional organisation for nurse leaders. The Australia College of Nursing considers the roles of community and primary health care nurses to be integral to chronic disease prevention and management in primary health care. Community and primary healthcare nurses have a long history of providing health care across communities—often to those who are marginalised or hard to reach or have limited access to traditional healthcare settings—and their services are embedded within communities. Communities, families and individuals engage with community and primary healthcare nurses across the various stages of life: maternal and child health nurses, school nurses, sexual health nurses, community nurses, home visiting nurses or palliative care nurses, just to name a few. The reach of nurses is unmatched by that of any other health profession trying to reach populations. Their interactions with individuals and their visitors, families and communities provide great opportunities for the delivery of health promotion messages and activities—opportunities that are not often harnessed.

As we know, the social determinants of health have a major influence on the health of individuals. Community and primary healthcare nurses provide care within the context of people's living conditions, environments and relationships and through the coordinating role they undertake to link people with services beyond the usual clinical settings to include such services as housing and employment services that the profession has a long history of working with.

People with chronic and complex conditions often require a multidisciplinary approach to care. It is important that the roles of nurses in coordinating and monitoring care for the complex needs of patients and the network of health professions that nurses work with and liaise with are recognised. ACN believes the opportunities exist for governments to enhance the role of community and primary healthcare nurses in the prevention and management of chronic and complex disease.

Healthcare service models in Australia are predominately designed to provide acute, episodic care and lack a strong focus on care integration and health promotion. Models are required that integrate nursing services with general practice and acute services and make better use of the nurse workforce. Medicare funding, which supports an episodic model of care, is no longer suitable for the patterns of chronic ill-health that have emerged in Australia. ACN supports the trialling of mixed funding models that include capitation funding, grants and outcome based payments. Such mixed funding models deliver a range of incentives that would better support the ongoing, multidisciplinary care that much of the community requires.

Lastly, nurse workforce planning is urgently required to support Australia's developing focus on primary health care. To date, no comprehensive data are available on the roles, distribution and number of nurses who work in primary health care. If more health care is to be shifted to the lower-cost primary healthcare settings, workforce planning will be needed to identify the number of primary healthcare nurses required and to plan for the systematic development of this workforce. Thank you.

Ms Booth : I represent APNA, which is the peak professional body for nurses working in primary health care. Our vision is for a healthy Australia through best practice primary healthcare nursing. Our mission is to improve the health of Australians through the delivery of quality, evidence based care by a bold and vibrant primary healthcare nurse workforce. APNA represents a vital cohort of nurses who work across all areas of primary health care, including general practice, and across all areas of Australia, from major cities to rural and remote outback.

Primary healthcare nurses, as Kathleen said, are one of the most widely distributed health workforces and are often the first point of contact that many Australians with chronic and complex illness have with our health care system. Primary healthcare nurses are the key drivers for successful population health and preventative health care in all settings that they work in, including general practice, aged care and community health facilities.

Nurses working in primary health care are uniquely placed to manage chronic disease. We possess the skills to deliver comprehensive chronic disease prevention and management programs and are particularly skilled at encouraging, supporting and educating consumers about self-managing and about providing and monitoring feedback on the patient's progress. Primary healthcare nurses also play a pivotal role in early intervention—helping to prevent complications and avoid hospitalisation, which is costly to the person, costly to their families and costly to the nation.

As the members of the committee are fully aware, the combination of the ageing population and the increasing burden of chronic disease presents a significant challenge to the sustainable provision of optimal health care in Australia. The contribution that primary healthcare nurses make to the delivery of care, where nurses play an important ongoing role in the management of the individuals' chronic disease—so monitoring, ongoing care, coaching—is already an important part of the solution to this challenge. Realising the potential of the nursing workforce will be critical as the demand for health services continues to grow. More cost-effective ways to improve access, especially for vulnerable groups, and deliver quality care is required.

Primary healthcare nurses are a substantial and growing component of the primary healthcare workforce. They work alongside other health professionals. Using evidence-based approaches, nurses play a major role in improving health outcomes through a multidisciplinary approach to care. One of the key points raised in our submission to the committee is the success of nurse clinics in dealing with chronic and complex care and with the coordination of care. Using a nurse clinical model, healthcare nurses working in multidisciplinary teams have their own caseloads and take lead responsibility for care of the patients. Patients are either referred to them directly by the GP, or the nurses play a key role in identifying patients at risk in their communities who would benefit from a much more coordinated approach to care. This can play a particularly important role in areas of workforce shortage—in rural and remote areas in particular, and in outer-urban fringes. Utilising nurses to their full scope of practice in the care of persons with chronic disease also frees up GP time, so GPs can then go on to see patients with more acute needs.

As my colleagues know, the projected nurse workforce shortage predicts that primary healthcare nurses will experience one of the largest shortfalls in the sector. The HWA paper—the last paper—estimated a workforce shortage of 27,000 by 2025. This comes at a time when the demand for services of these nurses in tackling the issues of complex and chronic disease has never been higher. The real chance of dealing with the looming health crisis is in the need to focus on recruiting and retaining more primary healthcare nurses. More nurses means more consumer-focused care and more cost-effective care, and leads to markedly improved outcomes.

At APNA, we are committed to developing and driving new initiatives which enhance primary care and optimise the role of primary healthcare nurses, particularly in chronic disease management and prevention. We are about to embark on a number of innovative projects aimed at enhancing workforce capabilities, including a number of projects to attract and support nurses transitioning into primary health care—so either new grads coming to the sector or moving from the tertiary sector into the primary healthcare sector, as well as programs to help build the capacity of the current workforce. We have significant expertise in this field. We have run a series of successful chronic disease management workshops for primary healthcare nurses all around the country.

APNA is also currently embarking on an ambitious program to develop an education and career framework for primary healthcare nurses as part of our commitment to growing a sustainable workforce. This is being implemented alongside our other projects aimed at supporting the health of the community by increasing access and encouraging the use of a multidisciplinary approach to care.

CHAIR: It was a six-minute introduction. All you are doing is reducing the amount of time we can ask you questions. We are going to run out of time to ask you questions, but you can keep doing your opening statements if you want to.

Ms Ryan : I think it is very good point. Can I ask my colleagues to pick two points out of your submission to hand over to the committee members, and then we will leave it at that. Otherwise, it is not going to work.

CHAIR: If you have long introduction statements, we can always take them as exhibits or submissions.

Ms Gibbs : Our emphasis is on Aboriginal medical services: wishing to have them supported if not enhanced with respect to any changes to primary healthcare funding arrangements—be it community controlled or publicly funded, because there is a mixture of both right across the country. The advantage that we find with community controlled Aboriginal medical services is that they provide a holistic approach to health, they provide a range of services, they look at the patient totally and they do not rely on fee-for-service, so when they have a patient they look at them all the time. They have a system of providing pathways for their health services and coordinated care, and I think that is important if you are going to deal with chronic diseases. That is the key thing that I would like to promote today.

CHAIR: Thanks.

Dr Grant : The key point that I would like to make is that a healthy adult life begins in infancy and early childhood. One of the core factors that we want to make prominent is that we need to not lose sight of primary prevention. We have to get in there before chronic disease takes place. Child and family health nurses are well-positioned and underutilised in doing that. At the moment, they are able to reach families—they have a very broad reach—and their reach particularly tends to things like healthy eating, prevention of obesity and prevention of diabetes, which are core beginning statements for chronic disease.

The second important point is that child and family health nurses around the country are presently constrained by different funding arrangements in different states and territories and nationally. We are primary health care but we are often clumped under acute care health provision. Different models mean that nurses do different things and are not enabled to reach the capacity of their scope of practice. What we would like to see are funding models that enable child and family health nurses to reach the potential of their scope of practice and therefore reach the potential of getting to those most-in-need families early in infancy.

Ms Ryan : I want to mention two things. In 2014, the World Economic Forum noted that in 2030 mental illness will cost $6 trillion a year. It is currently costing us $60 billion a year—13 per cent of our GDP—so we have to do something about mental health. I reinforce the fact that the Mental Health Nurse Incentive Program that you already have in your report is a good program that should be expanded to other areas of health care to enable nurses to manage chronic disease in other areas. I will leave it at that.

CHAIR: One of the questions we have here is about e-health, or internet health. We have heard about regional and remote areas. How much of a part can that play in preventive management of chronic health, particularly for remote and regional areas?

Ms Gibbs : The Northern Territory has been using e-health for quite some time, particularly in Aboriginal medical services. It allows for more ready-time communication and referral pathways—on time and with updated information of patient's records. It could well and truly be enhanced, but for those areas that do not have services on the ground, yes, e-health is important. It provides an access to services. It should not necessarily be the full substitute, but it does provide services.

Dr Grant : E-health covers a whole range of services and constructs, and we cannot assume that we are necessarily talking about the same thing. One of the most important things from a child and family health perspective—and we have looked at e-health records, beginning with infancy—is the challenge that only some members of the health profession are able to enter data on the existing trials. What we need are all members of the health profession, including nurses, to be able to enter data, which has been an absolute gap in some of the existing trials.

CHAIR: With regard to a lack of resources in certain areas, we have also heard—and I have given you an example from my home state of Western Australia, where in the CBD or metropolitan area the lower SES areas have less access to GPs—that in the areas where you probably need them less, they tend to migrate to those areas to set up their clinics. How do you, as nurses, play a role in trying to convince GPs to move into areas where you are most needed?

Ms Ryan : I want to make a comment on that. I do not know that it is our role to convince GPs—thank you—to do anything, as much it is not theirs to convince us!

CHAIR: I understand that.

Ms Ryan : I think the whole point is that we need to look at collaborative models of care. We have to stop thinking that GPs, psychiatrists and other people are going to be in those rural places because, effectively, they are not. They have not been to date. There have been many, many incentives to get them to go to those places, but they do not go there.

CHAIR: I am not just talking rural and regional.

Ms Ryan : No, I am not talking about rural either. I can give you perfect examples of where psychologists work in highly affluent areas, and we do not have psychologists providing better access in those lower SES areas, for all the reasons that you would know. But I think one of the roles that we cannot escape here is the emerging role of nurse practitioners and the ability for them to fill the gaps in regard to services.

I think the thing that is really important about e-health is that it enables people to work together collectively. It should not be any one person's job, and it should not be about, 'You do that, or, if you don't do it, I can do it.' We have to get over turf warfare these days. We have to get past that. Everyone has a role, and, until we actually start coming together at the table, putting our own baggage behind us and saying, 'This is about the community, and we have to collectively work together to make it better for our community and our people,' we are not going to get the goal that we want, which is collaborative and integrated health care, because we are all still worried about whether I have a shingle, I am a doctor, I am a nurse or whatever. We have to get past that. That is the reality.

CHAIR: Well said.

Dr Grant : I totally agree with what Kim is saying and about the role of nurse practitioners. There are some really exciting models coming out of Vancouver, for example, in early childhood, where there is nurse practitioner led primary-care provision in the hard-to-reach areas, in the homelessness services and in First Nation services. They are not practising independently away from the rest of the team. They are the hub of the team, they incorporate the team, and they are showing really great outcomes for decreasing vulnerability scales and increasing health outcomes.

The second really important point with all of this is the notion of, again, e-health and making sure that e-health is used throughout.

The third one in my mind is scholarships for people who are already living in regional, rural, remote and hard-to-reach populations who want to be able to undertake healthcare education but cannot because of their own circumstances. If we can increase scholarships for that cohort—I say 'cohort', but there are a number of cohorts of people out there—then we are actually training in place and getting people to return to their homes.

Ms Booth : I would add that there are already models using quite skilled nurses—not nurse practitioners but highly skilled nurses—particularly in some of the remote communities, where those nurses can follow protocols. Emergency patients come in—or kids with glue ear or kids who are unwell. They have protocols that they can follow. They can prescribe. They use telemedicine to relay any concerns to doctors working in the clinic, whether it be the Royal Darwin Hospital or the Royal Flying Doctor Service, and then convey their concerns and treat the patient on the site, and they do not have to evacuate that patient. So there are already some very innovative models set up.

For those areas of workforce shortage, particularly in outer urban fringes, I think we should also recognise that there is a lot of capacity in the nursing workforce there. There are nurses in those areas who can run those clinics for chronic disease and can do some of the preventative health stuff that does not necessarily need to be seen by the GP immediately. They can manage that. There could even be some prescribing rights for nurses in those areas of workforce shortage, where they can maybe do things like repeat prescriptions. They would not be the primary prescriber, but they could be in contact with the patient's GP and do repeat prescriptions. That might also—

Ms HALL: That does happen in some jurisdictions, doesn't it?

Ms Booth : It does happen in some jurisdictions but not all of them.

Ms Gibbs : I was going to offer up an example from a nurse practitioner role. That is Lesley Salem, one of our members, who actually received the nurse practitioner award this year. She works up in northern New South Wales across two AMSs and does a combination of in-clinic and outreach work, as well as in-home services, and has a focus on chronic disease. A lot of the work that they do does not just involve or target the Aboriginal community. They reach out to the socioeconomically disadvantaged. They actually go to people and reach out across the board to people who would not be able to afford to see a GP. Lesley's work and the AMS funding models allow people who could not afford a GP sessional payment to come to them or to access health services. I think there are a lot of advantages in what they want nurse practitioners to do. There are a lot of good models out there. It is about collaboration. It is working; it is having good referral pathways; it is doing the linking and the coordination roles. It is not like they are autonomous and working in competition. They do fill a gap and provide a very good service. Otherwise there would be a gap.

Ms HALL: I will probably roll 10 questions into one here because we are running out of time. We have heard today about the needs of interdisciplinary teams. We have heard about maybe looking outside the current funding model. With the interdisciplinary teams, some of the information we have been given is that they should be GP led. Other information that we have received is that maybe they should be allied health led. I suspect that the information that you would give us is that they should be nurse led.

Ms McLaughlin : No!

Ms HALL: There was also some information given to us that maybe it should be flexible and should be designed around the need of the person. Then, flicking into that funding models and moving from fee for service to a capitation funding—I can see how capitation funding would work really well with maternal and childcare nursing—then also looking across the funding between states and the Commonwealth. There are all these little silos that exist out there. How do you bring them together to get the best outcome in providing programs, education, prevention and monitoring for somebody living with a chronic health disease?

Ms McLaughlin : I think you have probably summed up well what our position would be. For someone with a chronic condition it will differ between people, depending on what their health needs are, as to who, and from which profession, the primary care provider would be. It needs to be specific to the person's or the community's needs.

Ms HALL: And that could change?

Ms McLaughlin : Absolutely, yes. It might be the mental health nurse. It might be the diabetes nurse educator that takes the lead of the team and is the link to all the necessary services. You are correct in terms of the funding models. We are not able to present today the model that works, but I think exploration and work on developing a model that supports that interdisciplinary working is needed.

Ms Ryan : Can I talk about the funding model in regard to the Mental Health Nurse Incentive Program? That is the only program which is funded the way it is funded. It is funded as block funding. The nurse and the GP or psychiatrist collaborate within that funding to do whatever it is that the client requires. Unlike other episodes of funding where it is fee for service, where you do an intervention and you get a particular payment for that, it is not like that. This amount of money goes to the practice, and if you need to see the patient every day for a week you see them; if you do not need to see them for six months—you decide, as a team—GP, psychiatrist, nurse, patient—what is required, and you are able to do within that what is required. That is the perfect type of funding that we need to have for chronic disease management. By virtue of being a chronic disease, there will be ebbs and flows in terms of what people need and who is required within that intervention at that time.

So there have to be different packages of funding in regard to chronic disease, because we cannot afford to keep doing it the way we fund health care. The perverse incentive is that the more people we get through the service, the more funding the service gets. We have to enable the service to do holistic care for people, whatever intervention they require and whoever it is that is needed. I think that the consumer should have more voice on who is leading their care, as opposed to health professionals. In the hospitals we have collaborative arrangements. The thing that people have to remember in terms of nursing, which is different to a lot of other parts of allied health, or maybe more aligned with GPs, is that when you call in a diabetes educator, a psychologist or an OT, you call them in to do a specific intervention. You ask them to do some sessions of CBT or to give some diabetes education. The whole difference between what nurses, and predominantly GPs, do is that they do all of that. If I am a mental health nurse I will also be looking after my mother that is having perinatal health issues; I will be looking after the diabetes because they have diabetes; I will be looking after a whole range of health and mental health conditions, not episodes of care. That is what we really have to focus on when we are looking at chronic disease, because chronic disease is not one thing. If you have cancer, you are 20 per cent more likely than the rest of the community to take your life after the first year after being diagnosed. The mental health nurse has to think about the cancer aspect and the cancer nurse has to think about the mental health aspect. It is about nurses, and predominantly GPs, doing the whole thing, not episodes of care. That is really important to remember in the management of chronic disease.

Dr Grant : There is one more thing that we have not said explicitly. I think that current funding models very much look at process outcomes. They are processes—how many times you have seen someone. That is what we measure. We do not measure the health outcomes. Under whatever blended funding model we come up with, because I do not think one model is going to solve the problems of the universe, it needs to be blended models for different situations.

CHAIR: It would be hard to get everyone to agree on it, too.

Dr Grant : Exactly. But what we need to be really mindful of is that we need to be measuring the client outcomes. Are they better? Have they had interventions that are working for them, on their terms and from their perspective? So outcome measures, not just process measures.

Ms CHESTERS: Just very quickly on the workforce. We have mentioned that. I agree that it is not your responsibility to get the doctors to go to regional areas. I am from Bendigo. We have our own challenges in allied health. But even within nursing there are workforce development challenges. Particularly thinking of the churn in mental health because of the challenging nature of mental health and mental health nursing across the board, particularly in Aboriginal health as well, do you have any ideas on how can we get on top of those workforce issues and encourage nurses to either step up or continue professional development so that we can have the workforce we need to tackle the chronic issues in this area?

Ms Ryan : I think there are a number of issues in that. I do not think that any of us have an answer to that, to be honest. I can speak from a mental health perspective, because obviously there is a big challenge. Probably the highest predicted workforce shortage into the future is in mental health. That is really troubling, given the increasing rate of chronic disease around mental health. So that is a challenge. We need to provide the nurses with the requisite skills to work in a particular area. One of the issues for mental health nurses, which does become a challenge, is the way our nursing education works. You do a comprehensive undergraduate degree, then you go and work in whatever area you want to work in. What worries me in some instances is the preparation for nurses to go and work in acute mental health services or in acute intensive care where they do not have the skills. We need to make sure that the nurses that are working in specialty areas—nursing is specialising because it is such a big body of knowledge—have the required skills to be confident to work in that place. That is a challenge for some of those people who do not have those skills.

The other thing that we need to look at in terms of nursing—we do not do it very well—is to allow nurses to move in and out of workplaces. So, for example, if you work in an acute mental health unit, that is where you work. You do not work two days in acute mental health then three days in the community, which would help support people with integration of care through inpatient services and the community, but also give them some down time from the high acuity that happens in inpatient services. There are quite a number of ways that we could look at supporting the nurses to stay in the workplace. I think that is a big challenge. I do not know that I have a solution around nursing. One of the biggest problems of mental health nursing is the stigma that is associated with mental health nursing. We have exactly the same stigma associated with mental health nursing as mental health patients have.

Ms McLaughlin : I could add a couple of things about retention in the rural areas, which is what you were talking about, in terms of nursing, to support the nurses working in those areas. Often there is a sense of professional isolation and poor access to professional development in order to maintain skills. There are a number of things, including access to professional development opportunities and also professional networking. The more we have multidisciplinary teams working, the more that sense of professional isolation is reduced. The supports from within a team can also give professional satisfaction. It is also important to enable nurses to work to their full scope of practice—which they often do in rural and remote areas, and I think you will find the most innovative practices are in those areas. Allowing nurses to work to their full scope of practice and enabling professional satisfaction also will assist in retention.

Ms Ryan : I often say at the moment that nurses are leaving nursing because they are suffering an existential crisis. They are leaving because they are not doing what they want to do. They are compromised every day in services they provide and they give up on it because they say, 'I'm not doing what I actually need to do for the patients.' For example, in the majority of mental health units in Australia, the first question that people ask in the morning, 'Who's going home today?' because they need the bed. That is not about quality care, and after a while the nurses say, 'I'm in a busy surgical ward. I actually haven't had the time to sit down and talk to my patients about what's really important.' I talk to many other nurses and I say to them, 'You've got to think about the mental health,' and they say, 'We haven't got time to ask people about their mental health. We're running around doing all these surgical procedures or medical things, and we're not able to do what we want to do as nurses,' and so they leave because they just cannot do it anymore.

Dr Grant : An issue that is not dissimilar is in child and family health nursing. I have mentioned before the issue of the disparate funding models. Those funding models constrain practice. In South Australia, for example, there are a set number of targets that the nurses need to achieve. Those targets are process based—they are not outcomes based—so the nurses are struggling to get those process targets done and, similarly, they are not able to enact the practice that they know. They have done their postgraduate education, they are skilled and they are knowledgeable, but they cannot enact that because they are having to meet these process targets because of the funding models. They are incredibly frustrated and they leave.

Ms Booth : Coming back to the new nursing graduates, that 30 per cent I think is the figure that cannot get a job when they leave university. That is a large number of nurses who are graduated, qualified and registered but cannot get a job. A lot of them tend to focus on trying to get a job in a tertiary sector because they have a really good grounding of background training. Part of the work that we are going to do at APNA is look at pilot programs—and we have government funding to do this—to try to encourage new graduates into primary health care, not just into general practice but into a number of areas, and to set up that education support that they need and some mentoring. Also in the pilot we will be offering some incentives to practices to take those nurses.

At the student level, the issue is enabling them to have experience in private practices. It is not just nurses; it is allied health as well. To get them into small private practices is really hard. You have to negotiate every single placement every time. There is no funding that comes with them. Medical students are funded and interns, if they do placements, get some funding support coming into general practice, but nurses absolutely do not at all. As I said, there is the need to develop those support programs so that, when nurses move into general practice, they feel like they have that mentoring to get them through at least that first year and get used to it.

Ms Gibbs : From an Aboriginal health perspective, the issues that we have around the health gap are not dissimilar in the Aboriginal and Torres Strait Islander nursing-midwifery workforce. That is an issue about racism. When we say, 'Close the gap,' a lot of the issues and barriers that people face with respect to getting health outcomes or even working or staying within nursing-midwifery—because we know that the first five years have the highest dropout rate—are issues of discrimination and racism that they face, either as a patient receiving services or as a staff member. A lot of people do not even realise that they are saying things or doing things that are offensive, discriminatory, or harmful, but there is a lot of that around. If you are going to address health and deliver good primary health care you have to do it from a culturally respectful point of view for the staff and the consumers. I do not think that we empower general practitioners, community health centres etc. to learn to develop a culturally safe environment. I think that is an issue.

The other issue is that, if we want to get a greater experience of Aboriginal health, it is very similar to general practice. Clinical placements are very, very hard to get either as a student or in a job straight out of university as a graduate working in an Aboriginal medical service—you are not going to do it without any background or experience. There is not a lot of support for that. Most clinical placements seem to be focused on acute care—the hospital system. There are not enough opportunities outside of acute care into primary health care, and if a student wants to do that it is not the norm within their school. They have to go and try and achieve that on their own, and they may not necessarily get the support to find those clinical placements. There is not enough of that support. There is more focus on providing support for a medical student to get a rural placement than any other placement around, and I think that needs to be addressed.

Ms CHESTERS: Would you say it is also similar for new and emerging communities—some of those cultural barriers that may exist?

Ms Gibbs : Yes, a lot of it. If we keep the focus on our nursing or our concept of health from our own perspective and we do not open up our eyes to try and look at health from somebody else's perspective, we are going to close down the communication between the individual and the health professional. That is a big problem. A lot of the problems we have are from that poor communication, so it is an education of the health profession broadly, not just particular health professions. I think there is a lack there.

CHAIR: Thank you for coming along today. Your evidence has been valuable. If you have been asked to provide additional information, could you do so by Thursday 15 October. If the committee has any further questions, which I think we might have, we will send them in writing to you from the secretariat. If there is any other information you think would help our inquiry in our report, please feel free to forward it through to us via the secretariat. Once again, thank you for coming along.