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Community Affairs Legislation Committee
Department of Health

Department of Health

CHAIR: I call this session to order. Senator Watts, you've got the call.

Senator WATT: Thank you. Could we get the Cancer Screening Register people back up? Okay. Thanks everyone. Great to have you back, Minister. We missed you.

Senator Scullion: Thanks.

Senator WATT: I had only just started asking questions about screening register before we moved on to other topics. I think, Mr Boyley, you were going to table a copy of the sort of update that you were providing us?

Mr Boyley : Yes.

Senator WATT: In the limited time we have got, I want to stick to matters around the contract with Telstra. Has the department sought any legal advice on whether the contract has been breached due to underperformance by Telstra?

Mr Boyley : We get legal advice as a normal course of business around the contract. I have been with this task force since May. I haven't seen any advice along those lines in relation to breach. Certainly, since my arrival the focus has been on getting this delivered—what do we need to do to make this work?—and working with Telstra to ensure they have the right people, the right resources, the right focus and the right assistance from us to get the register across the line.

Senator WATT: Just to take a step back, what I think you were telling us a little earlier was that, notwithstanding the performance issues around Telstra, and notwithstanding the range of issues there'd been along the way with delivery and notwithstanding the recommendations of this joint committee it's still the department's intention to plough on with Telstra and get this delivered?

Mr Boyley : Yes. That is the position that I stated before.

Ms Beauchamp : I will just add, in terms of the contract itself it's a robust contract based on milestones. In a sense only 15 million of the 220 has been paid out. Telstra Health has borne the risk of the delay. I think that contract that we have in place has been well thought through in terms of the Commonwealth carrying risks. I just wanted to reiterate something that the JCPAA picked up too, which is the complexity of the project, and some of the unanticipated complexity and delays in a sense in terms of the project that we took on and Telstra Health took on. I think there have been comments made by the JCPAA, and other additional comments, about the register that relate to the program and there are two separate things . There's the cancer screening program—for example, the loss of life-type issue—and then there's the register to back up the program. So, it's probably worth separating those two to fully understand how the project has been developing.

Senator WATT: Mr Boyley, I appreciate you've only been in the job a relatively short time, but Dr Studdert you've been around for a while as has Ms Beauchamp, neither of you are aware of the department having obtained legal advice as to whether the contract has been breached by Telstra due to underperformance?

Dr Studdert : No. As Mr Boyley said, there is ongoing legal advice as part of the project management team. But, yes, the delays have been real, understood and negotiated as we have gone. As the secretary just mentioned, as painful as they've been, they haven't actually cost us money, because we haven't paid money until milestones have been reached. Whilst it's been a slow and arduous process at times, we have made key milestones in recent times. With significant investment now in our own engagement and relationship with Telstra and their significant investment—quite frankly at very little gain for them in terms of budget—we feel we're at a point where we will get real deliverables and outcomes for the participants in the screening program, because—

Senator WATT: You can imagine my scepticism, given I feel like I've been hearing that for a while.

Dr Studdert : I guess I'd like to—

Senator WATT: I'm not having a go, but every estimates I have been assured it's just about to get better—

Ms Beauchamp : I've only been here 12 months, but now we do have a program, and we can go through the figures in terms of the women accessing that program, but we've also got a fully functional register.

Senator WATT: I might get you to table those figures. I think that's part of your update as well.

Mr Boyley : Yes.

Senator WATT: Under the contract, would the Commonwealth incur costs or penalties if it were to cancel the contract?

Mr Boyley : Putting aside whether there are legal grounds for termination or the like, when I consider a position as to whether we should continue with a project such as this or not, having done these for a number of years in other agencies, the view I form considers what the alternative is if we stop. If we pull out now and walk away, what are we left with? What does that mean in terms of support for the program that we have running? How do we manage cervical cancer screening in this country, given that we have migrated the state and territory registers into this register and most of them are now closed or closing? What are we left with if we stop and how do we move forward with another register? Procurement time frames for registers such as this are over 12 to 18 months before you've gone to market with your fully formed requirements that have taken you many months to prepare, selected a tenderer, negotiated terms and conditions, got a start-up period running, the team's on the ground and things are being built. You're talking 12 to 18 months delay minimum before you have even got to the starting gate. The question I ask myself is, is there a reasonable probability in my mind that the delivery can be achieved with the existing provider, with all the investment that they've made and with what I'm observing in terms of commitment, skilled resources, retaining those staff and the delivery they have done from May till now?

The opinion I've got is that we delivered the cervical component on 2 July. It went fully live. It supported the program, which has been in police since 1 December last year. Those results have all been applied to the individual records that were migrated from all the state and territory registers. The view I formed was, we have half of this thing delivered—

Dr Studdert : More than half.

Mr Boyley : and what would stopping give us? Stopping would give us half a register, which we would be hard pressed to take over and run ourselves. We would then have to procure someone else to build the rest of it.

Senator WATT: I suppose what has changed is that only a week ago a joint committee recommended that the department give consideration and report back to that committee as to whether it's in the Commonwealth's interests to terminate. Can I take it from what you have said that, if not that recommendation, the notion of terminating the contract has been considered and ruled out? Or is that something that will still be considered in light of the committee's recommendation?

Mr Boyley : When I arrived I considered that as part of the options for delivery. When you're walking into these roles, it is one of the options as part of any outsourced delivery at any stage, providing you have cause. I'm not entering into the legal rights or wrongs or whether we have cause or not. That's a separate discussion that I'm not qualified to give an answer on.

Ms Beauchamp : In the course of providing a formal response to the committee, which we will do—we've given our initial thoughts—of course we will do a proper cost benefit looking at what the options are and provide a more considered response.

Mr Boyley : Absolutely. The secretary's covered it far more succinctly than I was about to. I have given it one thought, but I will give it another thought. We will look at it in the due course.

Senator WATT: To my earlier question, I hear what you're saying, that in your view at the moment the department should not terminate the contract. What I'd still like to know is whether the department could terminate the contract legally and whether it would incur costs or penalties in doing so? Does anyone know the answer to that?

Mr Boyley : It's a complex answer.

Senator WATT: Most commercial contracts have termination clauses.

Mr Boyley : Absolutely. They are standard clauses in these types of contracts. As to whether the department would incur costs, that would depend on the grounds for termination, any actions we had done to contribute to any delays, all those sorts of factors.

Senator WATT: Could you come back to us on notice about that?

Mr Boyley : We will have to come back on notice. It is not a straightforward answer.

Senator WATT: Have a look at the contract and let us know what can be done.

Mr Boyley : I would like to be able to consider those comments in the context of the formal response to the committee.

Senator WATT: Another part of that recommendation 11 from the joint committee is that the department consider and report back on what penalties the Commonwealth could consider seeking from Telstra, given the significant extra costs incurred as a result of this delay. At our last estimates hearing in May, I think it was Ms Konti told the committee that Telstra had been paid about $11 million under the contract, but would be paid more once it delivered the cervical screening register in June. I think you said before they have now been paid $15 million.

Mr Boyley : Yes. The actual payments to date are $16.9 million, which includes some change requests that we made along the way to the tune of $30,000. But there is also the business-as-usual costs that have been running since the cervical component had been delivered. So the $15 million, plus we are paying $600,000 a month since they went live with the cervical screening component.

Senator WATT: That is what triggered that additional payment, was it?

Mr Boyley : The additional payment was the delivery of the cervical screening component, absolutely. There were a number of milestones within that.

Senator WATT: And that happened in June?

Mr Boyley : Yes, at the end of June.

Senator WATT: In May Ms Beauchamp and Dr Studdert clarified that payments were being delayed until Telstra met certain milestones, but the department had not at that point imposed any penalties. Is that still the case?

Mr Boyley : That is still the case.

Dr Studdert : In effect, the penalty is that they are not getting paid.

Senator WATT: But there are no additional financial penalties that they're required to pay?

Mr Boyley : No.

Senator WATT: You probably saw—I can table it if you need me to—a report from The Australian on 24 September titled 'Telstra Health's $50 million cancer screening delay'. That report talked about $50 million being diverted from Telstra to the Department of Human Services to fund the ongoing operation of the current bowel cancer screening register.

Mr Boyley : Yes.

Senator WATT: Was that $50 million delayed or denied?

Mr Boyley : In effect it's $50 million revenue forgone for Telstra.

Senator WATT: It's now a $170 million contract, effectively?

Mr Boyley : Roughly. If you are looking at the initial term of the contract, the $220 million, that's correct.

Senator WATT: So work that previously was going to be performed by Telstra will now be done by the Department of Human Services?

Mr Boyley : In essence, the costs foregone are relating to time they would have been receiving business-as-usual payments for running the register, which they simply won't get to do now because of the delay.

Senator WATT: But they will ultimately still run that register and receive payments for it at that point in time?

Mr Boyley : Yes. But it's a matter of how can you catch up revenue that you have foregone? What I'm saying is that it's within the entirety of the $220 million funding envelope. I haven't seen that article, but $50 million or thereabouts, instead of Telstra earning it for the register that should have been running on the original contractual budget schedule, has instead been used to pay for the DHS bowel screening register to continue for additional time.

Senator WATT: In May, Ms Konti also told us that there were provisions under the contract that would allow the department to penalise Telstra—impose financial penalties for poor performance. That hasn't occurred so far?

Mr Boyley : No. That would relate to service level agreements being breached.

Senator WATT: Surely by now things have got to a point that the contract allows you to impose financial penalties on Telstra for non-performance?

Mr Boyley : I would need to take that on notice. The question I think I would need to take on notice is, are there financial penalties triggered by the delay? My reading of the contract—it's about three inches thick—was that there were none that we should have or could have triggered for the delay.

Mr Paull : I might be able to help. The delay or non-payment of milestone payments through the implementation or the build phase is effectively a financial penalty. Once BAU operations commence, it's an outcomes-based contract. The lack of or non-achievement of the outcomes has financial penalties against it.

Senator WATT: When will the bowel screening register be delivered?

Mr Boyley : I have some dates I can give you. We indicated at the last Senate estimates, I believe, that it was going to be delivered inside the 2019 calendar year.

Senator WATT: Yes—the latter half of 2019.

Mr Boyley : I can give you an indication. We have been checking and working together with Telstra Health on the schedule to a point where we're now reasonably satisfied that it's feasible. It's been broken up into four releases. The first of those will be April 2019.

Senator WATT: Is this a milestone in April 2019?

Mr Boyley : It's not a milestone contractually, but what we've done is broken up the delivery of the bowel register into three blocks, effectively.

Senator WATT: What's the significance of April 2019? What happens then?

Mr Boyley : In April 2019 there will be key elements of some scope that was deferred from the cervical register component. There will be improved reporting, a business intelligence tool that will be available to external partners, including the state and territory cervical screening program managers. In August 2019 there will be the completion of all the functionality of the bowel screening register to support the National Bowel Cancer Screening Program and operations once transitioned has occurred. And in November 2019 we anticipate that the migration of the bowel screening data will have occurred from DHS and that the operations will be able to commence for the bowel screening register to be run by the NCSR.

Senator WATT: So it could go live in November 2019?

Mr Boyley : Yes.

Senator WATT: That would be a 2½ year delay from the original start date, if that time frame is met.

Mr Boyley : Yes. Then we will have some final mop-up work from earlier releases, basically a clean-up run of anything that's been deferred and missed along the way, in March 2020. But that's mop-up work, because the register will be running in November 2019 with the bowel screening component.

Senator WATT: Are there payments to Telstra triggered at each of those milestones?

Mr Boyley : Yes.

Senator WATT: Are you able to tell us the dollar figures?

Mr Boyley : I would need to take that on notice. I don't have to contract with me.

Senator WATT: The joint committee recommended you report back to them on when the new bowel screening register will be delivered. I suspect you probably have just done that by giving those milestones.

Mr Boyley : Absolutely. We will provide that in the official response as well.

Senator WATT: As I often do, when we're talking about this—I know this is before your time, Mr Boyley—we were told at the Senate inquiry about the legislation that it had to be passed early in 2016, and that the inefficient paper based processes that we have for the National Bowel Cancer Screening Register mean that, for example, when women move interstate their records and their capacity to be supported and followed up by a screening register can slip through the cracks. It's pretty easy to draw the conclusion that these delays are jeopardising people's health and safety, isn't it?

Dr Studdert : Can I correct something there? I think there's a mix there of two programs. The cervical screening program was the one where we had state-based registers and where, yes, there were some disconnects potentially if women moved between jurisdictions. The bowel screening program is already a national program and the register is a national register. From the get-go there will be no visible difference to the participants, which is now a large number of Australians between the ages of 50 and 74 getting kits every two years. The program is already fully operational and will continue to be. So it's the back of house, if you like, that changes with the transition to Telstra.

Senator DEAN SMITH: Just in the interests of full disclosure, earlier today I referenced the fact that I'm the chairman of the Joint Committee of Public Accounts and Audit. There's a media report—I think it was in the Herald Sun—on 18 October where the opposition health spokesman, Catherine King, says:

The Liberal Government's disastrous handling of their own privatisation of the critical cancer screening register has cost taxpayers millions, and risked the lives of Australian women due to delays with the new cervical cancer screening program replacing the old pap-smear test.

Is that an accurate statement?

Ms Beauchamp : I might ask our CMO to comment. I don't believe that is an accurate statement. I will get the expert to provide comments.

Prof. Murphy : I think a number of media and other people have misinterpreted a statement that was made in the original explanatory memorandum to the legislation that suggested that the renewal program would save 140 or a certain number of lives a year. But that modelling was done over the whole screening life of a woman, where the HPV screening picks up abnormalities about 10 to15 years before you get a developed cancer. There is no evidence that a seven-month delay in the HPV testing, which is all that happened with the register delay, will have any impact on cervical cancer detection. That modelling is only applicable over the whole lifetime of a woman being screened. It's not possible to extrapolate that back to a seven-month delay, where someone might have HPV detected seven months later than they would otherwise have done. At the time of the delay to the HPV screening we sought expert advice from all the people who'd been guiding the program, and they were very comfortable that that delay was not putting women's lives at risk. You could not interpret any number of cancers going undetected from that delay.

Senator DEAN SMITH: The additional comments to the JCPAA report, which was signed off by Labor members of the committee, said:

For the sake of clarity, and given the importance of this issue, the report would have benefited from a clear statement of our concerns regarding the impact on Australian women of the unacceptable delay by Health and Telstra Health in delivering the new program.

Have I heard correctly, Professor, that you're saying there have been no negative impacts?

Prof. Murphy : You simply cannot interpret from that original statement that over a woman's lifetime of screening, from 25 to quite an advanced age, the seven-month delay in access to HPV screening, which is a marginal benefit, would have any impact. I've actually written a letter to the Herald Sun suggesting that the record be corrected on that basis. We can table that letter if you would like us to.

Senator DEAN SMITH: Yes, please. Let's table that now.

Senator WATT: On that question, though, Professor Murphy, it is correct, isn't it, that the explanatory memorandum to the bill said, 'Once implemented, the changes to the National Cancer Screening Program are expected to prevent an additional 140 cervical cancers each year'?

Prof. Murphy : Yes, but that modelling was over the lifetime of a woman's screening. HPV detection occurs about 10 to 15 years before cancer. Over a lifetime of, say, 30 years of screening, given that some women may fail to come back for a pap smear or you might miss some evidential element of the pap smear, the marginal benefit of having the HPV test at an early age would add to that increased detection over a lifetime—but not over a seven-month delay; there's no modelling that would suggest that.

Senator WATT: I'm not saying necessarily that over the seven months is when exactly 140 people would be picked up. But, if the bill is saying that these changes will prevent an additional 140 cervical cancers each year, it's not unreasonable—

Prof. Murphy : It's each year over a woman's lifetime.

Senator WATT: Yes. I'm not saying it's over those seven months.

Prof. Murphy : The impact is cumulative. The detection of cancer is over a whole lifetime. It would add up to 140 women a year but it implies a modelling of the entire program of their screening, because HPV is a very-early-detection technique. It's well before you get abnormalities on the pap smear. The natural history of this disease is that, after chronic HPV infection, it can take 10 to 15 years to get the abnormalities that cause cancer.

Senator WATT: Sure. I take the point that this is over a lifetime. But if what we were told in the EM to the bill was that the changes would prevent 140 each year then it's reasonable to expect that.

Prof. Murphy : No, it's not, because the modelling that came to that 140 conclusion was based on a lifetime of screening for those women.

Senator WATT: If that's the case, why wouldn't we just push this whole thing back by five years?

Prof. Murphy : Because it is much more convenient and better for women. You have a five-yearly test, and if you can have those high-risk HPV detections earlier then the treatment and management is much less invasive.

Senator WATT: Exactly. So the earlier we can get this in place, the better.

Prof. Murphy : Yes, but we're one of the first countries in the world to move to HPV screening—

Senator WATT: It's great. I'm a big supporter. I'd just like it to happen.

Prof. Murphy : and a seven-month delay is, frankly, immaterial in that program.

Senator WATT: Really?

Prof. Murphy : Yes. That was the advice of our experts.

Senator WATT: Immaterial? Okay.

Prof. Murphy : In the program.

Senator WATT: I'll leave it at that.

Ms Beauchamp : That's what I was saying earlier. The availability of the test and the program is separate from the register to back up all the data and the histories.

Senator WATT: That's true. But, again, all I can do is keep pointing you to what we were told in the bill about the screening program itself. It was going to be about protecting more women from cervical cancer, and that's why we want to get it done as quickly as possible.

Senator DI NATALE: I just don't understand how you can make a statement that delaying this test means that some preventable cervical cancers won't be prevented?

Prof. Murphy : All the modelling that we've done, as I said, showed the advantage of this test is that, over a lifetime of pap smear screening, some women may miss a screen; some early abnormalities may not be detected. But in the main, the pap smear is a very effective test. This is a marginal additional benefit. If you cumulatively add that up over a whole lifetime screening, you do get significant savings.

Senator DI NATALE: But you might take issue at 80.

Prof. Murphy : Yes.

Senator DI NATALE: But there's a benefit of this over current—

Prof. Murphy : There is, but nobody has modelled it.

Senator DI NATALE: But it has to have some effect. I mean, it is likely that, whether it's a small number—one, two, whatever it might be—

Prof. Murphy : You could postulate and try to do some modelling on that line, but we're talking about—

Senator DI NATALE: You know that you're introducing a screening test because you would be able to pick up what would be a preventable illness.

Prof. Murphy : That is correct.

Senator DI NATALE: And if the evidence base behind that test is strong enough for you to implement the test then delaying the test means you aren't going to be picking up some potentially preventable illnesses. That's just screening 101.

Prof. Murphy : Indeed. But over what is a very brief period, if someone had chronic HPV detected in May last year or December last year, it really wouldn't matter all that much, because they would have a 10 to 15 year development of the cancer. So I think, sure, you could do some detailed modelling; you might be able to suggest one or two. But the point I was making was that modelling of 140 women a year was based on a lifetime of screening.

Senator DI NATALE: No, I understand that.

Senator DEAN SMITH: We've had time to circulate your letter to the editor of the Herald Sun and I might just read the whole paragraph. It says:

The claim published on the 18th of October 2018 in an article by Sue Dunlevy, National Health Correspondent, the Herald Sun, that around 80 Australian women could have developed cervical cancer because of serious delays in the rollout of the National Cancer Screening Register by Telstra Health is alarmist and false and undermines the successful implementation of the national cervical screening program.

Are they are your words?

Prof. Murphy : They are my words, yes.

Senator DEAN SMITH: Why are they alarmist and false?

Prof. Murphy : Because anything in my mind that creates fear in the community that a risk of cancer is increased is alarmist. I think women have a right to be properly informed and the suggestion that you could draw from that article that a significant number of women's lives might be put at risk by this delay is untrue and it's alarmist. As Ms Beauchamp said, we need to distinguish between the issues with the register, which have been well discussed today, and the highly successful implementation of the renewal, the HPV screening liquid based cytology, which has gone really well and is very well accepted by the profession, the pathologists and is functioning extremely well. So I think the new program was introduced really well. There are obviously issues to be resolved with the register. But I think the two should not be conflated.

Senator DEAN SMITH: At the end of your letter, you go on to say that since the 1st of December 2017, 1,342,688 women have received an HPV screening test and, as at the 17th of October 2018, 2,208,556 electronic pathology results have been received by the register. That's an accurate statement obviously?

Prof. Murphy : That's true, yes.

Senator DEAN SMITH: Is it your intention to make that letter available to the JCPAA?

Prof. Murphy : We can do so.

Senator DEAN SMITH: You may want to incorporate the letter.

Prof. Murphy : Subject to my boss's approval.

Senator DEAN SMITH: Just reminding people too, who might be listening at home, you're not a mere bureaucrat, you are the Chief Medical Officer of Commonwealth.

Prof. Murphy : That's right.

Senator DEAN SMITH: Thanks very much. I mean that with all due respect. This is just not—

Senator WATT: There's one of him and about 300 of them!

Senator DEAN SMITH: Even Senator Di Natale will respect this. This is not just an ordinary letter with the Commonwealth crest; this is a letter signed by Chief Medical Officer of the Commonwealth. Thank you very much, Professor Murphy.

Senator Scullion: It is probably worth noting, through you, Madam Chair, that I understand this was sent only on 19 October. It's a letter to the editor of the Herald Sun and it hasn't been published as yet. We can only hope for the best.

Senator WATT: Mustn't have made the cut.

Senator Scullion: Obviously not.

Senator WATT: They have very high standards at the Herald Sun.

Senator Scullion: Indeed.

Senator DEAN SMITH: But even you would correct the record, Senator Watt, if you were significantly wrong.

Senator WATT: And I'm sure the Herald Sun would publish my letter if they thought it was worthy—with all due respect, Professor Murphy. We are done on that.

Senator DI NATALE: Can I ask questions on the 2010 Henry tax review, which suggested changes to alcohol taxation on both economic and health grounds. Has there been any work done by the department to look at alcohol taxation reform and different models for that?

Dr Studdert : I could say with some confidence—I will wait for my colleagues to get to the table—that, in recent times, some years we have not done any work on that, and, in fact, nor would we; that would be a matter for the Treasury.

Senator DI NATALE: You haven't done any work in that space at all?

Dr Studdert : No.

Senator DI NATALE: I'm not surprised. I'm interested in the recent debate around pill testing. Do you have any stats on how many deaths of young people attending music festivals are attributed to untested drugs over the last 10 years?

Dr Studdert : No.

Senator DI NATALE: Could you provide—

Dr Studdert : We could certainly look to some of the research institutes that we fund or if, elsewhere in the literature, there is some data on that. But we would have to go to our state and territory colleagues and emergency services to get that sort of data. We would be happy to provide what we can.

Senator DI NATALE: Good. Thank you. Are there any other commodities in Australia where government believes that consumers are safer not knowing whether they are contaminated with toxic substances, rather than knowing that information?

Dr Studdert : I think you're talking about a situation with illicit substances. I would imagine there are plenty of circumstances where people are using illicit substances where they're not fully aware of what the contents are.

Senator DI NATALE: Regardless of whether they are illicit or licit, the principle remains. Do you believe consumers are safer knowing what they're about to ingest rather than not knowing?

Dr Studdert : That's a matter of opinion that you're asking me.

Senator DI NATALE: You're obviously involved in the development of government policy around these areas, and I'm asking you a specific question—whether you think individuals are safer not knowing what's in a product rather than knowing what's in a product?

Dr Studdert : I think you're leading me to give an answer where clearly it is not part of government policy to engage on this particular issue. It's largely a matter for the states and territories and their policies around regulation of music festivals and other such events. The position of the federal government, which doesn't have any jurisdiction in this space, to a large degree, is that they're not supportive.

Senator DI NATALE: Is the government aware that when this was done at a recent ACT festival, Groovin the Moo, a number of pills that were tested and found to have potentially dangerous contents were discarded, saving these people from potentially fatal consequences?

Dr Studdert : We are aware of the outcomes of that trial. The Chief Health Officer of the ACT shared that with a jurisdictional group sometime after that festival, yes.

Senator DI NATALE: Professor Murphy, are you aware of the results of the Groovin the Moo pill testing?

Prof. Murphy : Not specifically. I've heard the media reports. I haven't specifically been made aware of them.

Senator DI NATALE: Have you seen any of the international literature that shows that people are much more likely to discard a pill if it's been tested and found to have been contaminated?

Prof. Murphy : I've seen some literature, yes.

Senator DI NATALE: What's the objective of government policy here?

Prof. Murphy : I think you'd have to ask government.

Senator DI NATALE: What's the objective of government policy here? You have an intervention that could potentially save young kids' lives. Why aren't we doing it?

Senator Scullion: As the department just indicated, this is not a matter that is controlled by the government or by Commonwealth government legislation. This is, in fact, a matter for the states and territories. As you've indicated, the trial was conducted by the Australian Capital Territory. We are but observers in this matter.

Senator DI NATALE: Despite the fact that the Australian government did its best to prevent that trial from happening?

Prof. Murphy : Indeed.

Dr Studdert : We had no role in that trial.

Prof. Murphy : None—no involvement at all.

Senator DI NATALE: Some people will beg to differ about that. Can I ask you then about another issue around illicit drugs, particularly going to oral substitution therapies—methadone, buprenorphine?

Dr Studdert : Opioid substitution therapies?

Senator DI NATALE: Yes, opiates—methadone, buprenorphine. Do you have average costs for methadone and buprenorphine dispensing? There's obviously the dispensing fee. What's the average cost associated with a dispensing fee now?

Mr Laffan : Sorry, I don't have a number per dose, but for 2016-17 there was $60 million provided by the government for buprenorphine, methadone and Suboxone.

Senator DI NATALE: That's the cost of the drug, yes?

Mr Laffan : That's correct.

Senator DI NATALE: But there's still a dispensing fee at pharmacies?

Dr Studdert : That might be a question best for our pharmaceutical benefits people because it is a program run—

Senator DI NATALE: Okay. I might leave that there. Can I go to the issue of obesity. There was recently a COAG announcement around an obesity strategy. Do you want to speak about that?

Ms Soper : Health ministers agreed that there would be a national obesity strategy. Minister McKenzie advised the CHC that the Australian government would develop a suite of activities to address obesity prevalence in rural and regional areas. The CHC also endorsed an obesity summit to identify and prioritise further action to reduce the impact obesity has on the Australian community and health system, including efforts in primary and secondary prevention to reflect that prevention occurs in health and other settings. They also noted that priority action should include whole-of-government, economy and community efforts as well as specific actions that can be progressed in the public health system.

Senator DI NATALE: Has the federal government committed to the national summit?

Ms Soper : Yes.

Senator DI NATALE: Have you got any details about when that's going to occur?

Dr Studdert : I think it's very early days. The meeting was only just over a week ago, and we are working with other jurisdictions on that.

Senator DI NATALE: Any expectation when that might be?

Dr Studdert : We're looking at the early part of next year.

Ms Soper : Next calendar year.

Senator DI NATALE: Early next year?

Dr Studdert : Yes.

Senator DI NATALE: You mentioned a range of primary and secondary prevention strategies. Has the government given any consideration to the introduction of a sugar-sweetened beverages tax?

Ms Soper : No, it hasn't.

Senator DI NATALE: You haven't done any work on this?

Dr Studdert : No.

Senator DI NATALE: You haven't had any consultation with industry on this?

Dr Studdert : No.

Senator DI NATALE: In terms of advertising of junk food to children, particularly during children's viewing hours, have you done any work in that area?

Dr Studdert : No. There's been some work around exposure in children's sports settings that's been done across COAG.

Ms Flynn : Yes. It's been looked at by the jurisdictions of the Commonwealth in terms of settings: school settings, sport and recreational settings—areas of that nature.

Senator DI NATALE: But nothing in the space of advertising, particularly TV advertising?

Ms Flynn : No.

Senator DI NATALE: Where they get most of their exposure?

Ms Flynn : No.

Senator DI NATALE: When you talk about primary and secondary prevention, what are you talking about apart from sports settings?

Dr Studdert : As I think we've discussed before, there are a range of programs the government's supporting with the Heart Foundation. There is the Healthy Heart Initiative, the Health Star Rating program and dietary guidelines where we continue to work and promote through various programs. There's the Girls Make Your Move campaign. Quite a significant part of the sport package which we were talking about earlier is targeting physical inactivity in school settings, for the physically inactive, for older Australians. That was a big part of the investment in that package, largely with a focus on obesity and chronic disease prevention.

Senator DI NATALE: Specifically looking at school settings, has any work been done around harmonising the national guidelines around exposure to junk food within schools—vending machines, tuckshops?

Ms Flynn : We've taken a first step, which is to develop some criteria for what we mean by junk food, because one person's junk food is somebody else's okay food. An example would be salsa. You can have a healthy salsa or one that's high in fat and salt. So the jurisdiction—

Senator DI NATALE: Coke?

Ms Flynn : Yes.

Senator DI NATALE: You reckon that's junk food?

Ms Flynn : Well, yes—

Senator DI NATALE: Sugar-sweetened beverages?

Ms Flynn : if it meets the criteria. When they meet the criteria, these foods would not be sold in school canteens. That's an agreement that has to be driven through state and territory protocols and legislation.

Senator DI NATALE: What's the federal government's role in that?

Ms Flynn : We have funded the NHMRC to help unpack what we mean by 'discretionary foods' and to fill out the criteria that we're talking about.

Senator DI NATALE: There's a bunch of stuff that's already being sold right now that I don't think anyone would debate, like when you have a vending machine selling soft drink. You know, if it looks like a duck and quacks like a duck—why can't we get movement on this?

Ms Flynn : It's actually quite a bit more complicated than that. If you take, for example, yoghurts—

Senator DI NATALE: I'm talking about vending machines that sell sugar-sweetened beverages.

Ms Flynn : But I just want to give an example. Yoghurts are a known core food, but if you throw in some choc bits and confectionary and that kind of thing then it's not a core food anymore. There are a range of mixed foods, and we have to be quite specific about the criteria that we're using so that everybody understands what foods are in and what foods are out.

Senator DI NATALE: All I'm saying is that there are a number of foods that we would all agree should be out. Why do we have to wait?

Ms Flynn : A lot of those foods are out, in school canteens, right now. It's the in-between foods where the confusion is happening.

Senator DI NATALE: There are school canteens that still sell sugar-sweetened beverages.

Dr Studdert : Again, this is a matter for the states and territories and their administration of schools, but we are trying to work collaboratively with the states and territories to address some of the stumbling blocks that people encounter when they try to work on these initiatives.

Senator DI NATALE: I'm up to Health Care Homes—a few questions on that. Are we happy to go to 2.5?

Senator WATT: Actually, we did have one in what is probably prevention, as well—2.4? Should I knock that over now?


Senator WATT: Minister Scullion, these ones probably should come to you. As the Minister for Indigenous Affairs, you would have seen a lot of evidence of the scourge of tobacco in Indigenous communities.

Senator Scullion: Indeed I have.

Senator WATT: Yes. What have you seen? How would you describe the impact of tobacco on Indigenous communities?

Senator Scullion: Well, the impact is in a number of ways, but I observe, particularly in remote communities, that tobacco appears to me to be used in a far greater way, across a much wider demographic, than I would see in similar communities in mainstream Australia.

Senator WATT: What sort of impact have you seen it having in those communities, on the health of—

Senator Scullion: Part of the impact is a financial impact. You don't often see Aboriginal people with a packet of cigarettes. There is a packet of cigarettes produced and, because of demand, it's shared. That's something that has a significant impact on the amount of cigarettes that are available in communities. I think price is having a significant impact.

Senator WATT: Given we're in Health estimates, what about the health impact on Indigenous communities? What have you witnessed yourself?

Senator Scullion: I've been witnessing this over a number of decades. Unsurprisingly, in people who've smoked for a long time, we're seeing them become far less mobile, far less active, as a consequence of having been smokers for most of their life; we're seeing emphysema and those sorts of presentations. But these are only anecdotal presentations. I'm sure Caroline Edwards would have a much more clinical experience.

Senator WATT: The reason I'm asking you is: frankly, you spend a lot more time in Indigenous communities than I do, or probably anyone here does, given that you're a Northern Territory senator and the minister. Have you seen evidence that it is contributing to people living shorter lives?

Senator Scullion: Not specifically. I mean, it's not something you observe, because it's not something you see instantly, but certainly those are matters that I think would be the same wherever you find yourself. I think smoking affects poorer people—that is probably a reasonable expression.

Senator WATT: I think you said you've seen evidence of higher emphysema presentations and things like that?

Senator Scullion: Yes. I'm not speaking from an evidentiary process, just from my personal experience.

Senator WATT: Just from your own experiences?

Senator Scullion: Indeed.

Senator WATT: Have you seen lung cancer, things like that?

Senator Scullion: I'd say anecdotally I have seen more than others, but I think my earlier comment is probably a reflection of what most people see in most parts of Australia, where there are poorer people present.

Senator WATT: Yes. Are you aware that, partly because of the higher Indigenous population in the Northern Territory, the smoking rate in the Northern Territory is far higher than the rest of Australia? I think the rate is 46 per cent in the Northern Territory.

Senator Scullion: Yes, I understand that there are higher presentations in the Northern Territory and part of that, of course, is because of the higher level of the population in the Territory.

Senator WATT: A higher level of Indigenous population—

Senator Scullion: There are more Aboriginal people. It is well over 30 per cent.

Senator WATT: and a higher level of smoking in those communities?

Senator Scullion: Indeed.

Senator WATT: Does the National Party still accept political donations from tobacco companies?

Senator Scullion: I'm not sure. You'll have to speak to the party on that. It's not something I'd be across. I'm a member of the Country Liberal Party.

Senator WATT: But aren't you the leader of the National Party in the Senate?

Senator Scullion: I am.

Senator WATT: So wouldn't you have bit of an idea about who's making donations to your party and whether they might include tobacco companies?

Senator Scullion: No, that's a matter for the party and the party president. I have absolutely no idea about those matters.

Senator WATT: Do you know whether tobacco companies have made donations this year, last year?

Senator Scullion: No. I can remember a few years ago this becoming an issue. Questions were asked in the Senate—I can't recall if they were by you—along similar lines but they weren't asked of me; they were asked of former senator Nash. That's my only recollection of this matter.

Senator WATT: I asked Senator McKenzie, Deputy Leader of the Nationals, who said much the same as you're saying now—that it's not a matter for you; it's a matter for the National Party. We have just gone through this. Whether or not it's your role as Minister for Indigenous Affairs, you're a Northern Territory senator. You've talked to us about the impact you have seen from tobacco. Don't you think you could exercise a bit of leadership as leader of the National Party in the Senate?

Senator Scullion: These are, as I said, matters for the National Party and I don't think you should assume anything about issues that happen and discussions that happen within the National Party. I don't see that Senate estimates about health is a place to discuss that. But in answer directly to your question, my last recollection was it was Senator Nash but I stand corrected; it may well have been Senator McKenzie. But I don't have any other knowledge of that matter.

Senator WATT: Are you aware that Labor stopped taking tobacco donations 14 years ago, and even your coalition partner, the Liberals, stopped five years ago? Clearly, some effort was made by the parliamentary wing to stop the organisational wing of those parties taking donations. Couldn't you do the same?

Senator Scullion: I wasn't sure, and thank you for the accuracy around the dates, but, yes, I was vaguely aware that both the Liberal Party and the Labor Party had stopped taking donations from tobacco companies.

Senator WATT: Are you prepared to raise this issue with the National Party organisation?

Senator Scullion: As I said, I'm not prepared to talk about those matters, and you shouldn't make the assumption that I haven't already.

Senator WATT: So have you raised those matters?

Senator Scullion: I'm not speaking about matters within the National Party or in the Country Liberal Party at these estimates.

Senator WATT: I think you know where I'm going with this. It feels like it would be the right thing to do given the impact it's having on both your own Territory and the Indigenous community.

Senator Scullion: I consider that you've made your point and it's understood.

Senator WATT: Thanks, Minister. That's it for us for outcome 2.


CHAIR: We will now move on to outcome 4.

Senator WATT: Sorry, Ms Beauchamp. We would like the AIHW just to stay for a little while longer if that's all right.

Ms Beauchamp : Okay. I'm just confirming.

Senator DI NATALE: I would like an update re progress on the MBS review. I understand it was due to conclude by the end of 2018. Is that right?

Mr Weiss : There was an ambition early this year to have completed the clinical elements of the MBS review by the end of calendar 2018. The chair of the task force has recently advised the Minister for Health that that work is likely to slip into the early part of 2019.

Senator DI NATALE: So there is a blowout with the time line?

Mr Weiss : In the 2017-18 budget, the government agreed to three years worth of additional funding and activity for the MBS review. Subsequently there was an ambition to bring that forward by—

Senator DI NATALE: It wasn't an ambition. I came to estimates a number of times, and you said you were going to have it done by the end of the year.

Mr Weiss : It was the ambition to have it done by end of calendar 2018, which would have been approximately 18 months ahead of the timetable announced in the 2017-18 budget. That ambitious timetable will not be met, but it should be finished in the first half of calendar 2019.

Senator DI NATALE: You didn't talk about it as an ambitious timetable when I asked you at the previous estimates hearing when it was going to be finished. You said it was going to be finished at the end of this year, and it's not.

Ms Beauchamp : Senator, can I give you a reassurance that, of the 5,700 items in MBS, I think we'll have 90 per cent done by the end of this calendar year.

Senator DI NATALE: Will those 90 per cent be made public, or are you going to have to wait?

Ms Beauchamp : That will be a decision for the minister.

Senator DI NATALE: So it's not going to be concluded. Whether you've done 90 per cent or not is irrelevant to me. The only issue that's relevant here is that we've had previous estimates hearings where I've followed this closely. We were assured it was going to be done by the end of the year. It's not, and we won't get access to the information. Excuse my cynicism, but there's every chance we're not going to get to it before the next election.

Ms Shakespeare : We need to make sure that the review reports are complete and that their work is done properly. Part of that work is targeted consultations with stakeholder groups. Given we have quite a few reports coming out of the MBS task force all at the same time, some of those stakeholder groups have asked if they can have additional time to comment on what are fairly long, technical reports. In light of that feedback, I think the task force has made the reasonable decision that it needs to continue on for a few months into next year.

Senator DI NATALE: I understand all that. It doesn't distract from the fact that we were supposed to have had the report done by the end of this year and it's not going to be done. So what is the current time line? What does 'early next year' mean?

Ms Shakespeare : I think it's in the first part of next year. We'll need to see how we go.

Senator DI NATALE: What's the first part of next year? Is it January? Is it February? Is it March? Is it April?

Ms Shakespeare : I don't know that we should be setting hard deadlines on this. The taskforce would like to finish its clinical reports and provide advice to government. A longer time will then be required to respond to many of the recommendations, but I think the primary interest here is having reports that reflect what is best practice in clinical practice under the MBS. If it takes a little longer to reach that point, that's the main objective.

Senator DI NATALE: Absolutely, but again we were told at a number of estimates hearings that it would be done by the end of this year. There just happens to be an election around the corner, and it's going to be at some point next year. That gives us no certainty as to whether this thing's actually going to be done before the next election. How many of the recommendations from the taskforce and related clinical committees have already been rejected by government?

Mr Weiss : From memory, there have been 103 recommendations provided to the government, and 92 have been accepted or accepted in part. The remaining 11 are still being considered by government. I'm not aware of a recommendation that's been rejected.

Senator DI NATALE: Have those recommendations been implemented and taken effect already?

Mr Weiss : The next batch of recommendations will take effect on 1 November.

Senator DI NATALE: Have you been able to demonstrate any savings already from the previous recommendations?

Ms Beauchamp : We have actually provided that information in questions on notice.

Senator DI NATALE: It should be easy, then, to get an answer.

Ms Shakespeare : It's estimated. In some cases, we have announced budget decisions and provided further follow-up information about the estimated savings from the implementation of government responses to a number of the recommendations.

Senator DI NATALE: Do you want to give me a total figure on estimated savings?

Ms Shakespeare : I think the total figures have been published in each of the budget updates. That included government responses to taskforce recommendations. The material that the secretary just referred to is in response to questions on notice from senators about particular groups of MBS items.

Senator DI NATALE: Can you give me a global figure?

Mr Weiss : At previous estimates we referred to a figure of about $600 million. They're the figures published in either budgets or MYEFOs. They're the forward estimates for the relevant budget or MYEFO. You can't just add them up and call it $600 million. That's the figure that's been discussed in previous estimates.

Senator DI NATALE: How many new items are going to come online from 1 November?

Ms Shakespeare : For instance, there are changes to—

Senator DI NATALE: You don't need to talk me through them specifically. How many changes—

Ms Shakespeare : I'm not sure that we can give you exact numbers. Some of the measures relate to groups of items. It is actually quite difficult when items are being restructured to say, 'This many MBS items are affected by the changes.' We can take you through what the general changes are.

Senator DI NATALE: Perhaps I'll ask you to do that on notice, given the time frame.

Senator WATT: Could I just ask one about the time frame for the review? The 2017 budget included funding for the review to run until June 2020.

Senator DI NATALE: That was going to be my next question.

Senator WATT: Sorry.

Senator DI NATALE: No, it's all right; go ahead.

Senator WATT: What you've told us is that you think it's more likely to be early 2019.

Ms Shakespeare : That's for the completion of the clinical reviews by the MBS taskforce. Those reviews then require government responses to be developed to them and then implemented. That work will go on for a period after.

Senator WATT: So the review, as a whole, wouldn't be completed until, roughly, June 2020?

Ms Shakespeare : We're still going to be looking at recommendations that we haven't seen yet from the taskforce. The size of the implementation associated with those is a bit difficult to tell until we've seen the recommendations.

Senator DI NATALE: Do we have a commitment that those savings are being reinvested back into health?

Ms Shakespeare : Yes. I think the government has included that commitment in budget papers and certainly in material around budget measures.

Senator DI NATALE: I think we had this discussion at Senate estimates last time and there was a bit of argy-bargy about exactly how that was accounted for. It's probably not in anyone's benefit to revisit that.

Ms Shakespeare : I can remind you that MBS is growing by $4.8 billion over the forward estimates. That includes those reductions that might be associated with some of the implementation of the MBS taskforce.

Senator DI NATALE: At this stage, you're not offering any commitment as to when this will be completed. Is that because you offered a commitment to have it done by the end by this year and you weren't able to meet that and you're just reluctant to give us a commitment to next year?

Ms Shakespeare : As I said, we certainly need to involve quite a few of the medical stakeholder groups in the process of finalising some of the reports. They've already asked us for additional time to consider some of the more complex reports, some of which run to about 700 pages. The government certainly would like to finalise the MBS reviews as early as possible, but we need to make sure that we're doing that in a way that's not impacting on all of the medical groups that need to be involved in the process.

Senator DI NATALE: I hear that there are some doctors who are a bit annoyed and don't feel they've been notified when changes occurred. How do you communicate changes to doctors about item numbers?

Ms Shakespeare : We have fairly well-established processes for making sure that doctors are involved in making changes to the MBS and are aware of changes. We rely very heavily on medical colleges to help us with this. So, any changes, whether as a result of the MBS reviews or if we have new items or changes to items as a result of—

Senator DI NATALE: So it's within the existing framework for how, as a GP, you'd find out whether there'd be something—a new item number, for example—listed, yes?

Ms Shakespeare : Those are fairly longstanding processes where we do make sure that items are developed with input from the medical colleges, so that they're giving us clinical input to make sure that the items and the restrictions make sense and are implementable in practice. But then the colleges also, in their role as educating doctors, take a strong role in letting people know when there are changes to the MBS. We have other departmental and Department of Human Services approaches to try and make sure people are aware of changes. There's askMBS and there's targeted consultation information that we provide to the sector. So we have a range of strategies.

Senator DI NATALE: Do you have any questions on the MBS review?

Senator WATT: Yes, just a couple. How many clinical committees are there?

Mr Simpson : Around 70 clinical committees.

Senator WATT: Seventy?

Mr Simpson : Around 70—over the life of the review. Some of those have concluded, but we expect around 70, and maybe some 60 to 70 clinical reports.

Senator WATT: I don't think you've given these figures already. How many are yet to report?

Mr Simpson : It would be in the order of between 30 and 40, but I'd probably have to take that on notice to give you an exact figure.

Senator WATT: Okay, if you could. Are there any that haven't yet met?

Mr Simpson : We have one meeting for the first time next week, but it's only considering about 20 items, so we're anticipating that it will only require a couple of meetings. The report should be able to be considered by the task force by the end of the year or early in the new year.

Senator WATT: Which one is that?

Mr Simpson : Optometry. There may be others, but I'd have to confirm for you.

Senator WATT: So one that you know of and there might be others?

Mr Simpson : Yes—just ensuring that we've covered off all of the items out of the 5,700 on the schedule going on at the moment.

Senator WATT: But you're confident that the review can be completed, despite that committee not having met yet and possibly others?

Mr Simpson : The taskforce has run nearly 70 committees. They have got their processes very well worked through, after three years of doing the work.

Senator WATT: We do have other questions on medical benefits but not on the review. So we still have others on 4.1.

Senator WATERS: I've got none on the review, but I've got less than five minutes on another matter, and then I'm going to another committee.

Senator WATT: In 4.1?

Senator WATERS: In 4.1, yes.

Senator WATT: You go.

Senator WATERS: Thank you, Chair, with your permission. I have questions about abortion and how the feds can get involved more, now that Queensland has decriminalised abortion or now that the bill has passed. Are you the right folk here for that?

Ms Beauchamp : Yes.

Ms Shakespeare : Yes, MBS and PBS.

Senator WATERS: Great. Can you walk me through—and these are genuine questions, because I don't know the answers—what the Commonwealth can now do, in terms of provision of pregnancy termination services through public hospitals, for example? What sorts of policy interventions could the Commonwealth now have to assist Queensland women, given that abortion has been now decriminalised?

Ms Shakespeare : We probably can't help as much on the public hospital side. Hospital funding was in an earlier outcome today. So we might need to take that on notice for you.

Senator WATERS: Okay.

Ms Shakespeare : Under the Medicare Benefits Schedule, though, we do have items that are available for, amongst other things, people to claim when they've had a termination of pregnancy. There are also items that can apply if a woman has had a miscarriage. So those items exist in the MBS, and, where people receive their hospital services as a private patient in Queensland hospitals, they would be able to claim those services and rebates.

Senator WATERS: Forgive my ignorance—why only for private hospitals?

Ms Shakespeare : We fund public hospitals, for public patients, through the National Health Reform Agreement, which is a separate sort of funding arrangement.

Senator WATERS: Does that mean those costs are covered and the consumer is not out of pocket?

Ms Shakespeare : Generally, for public patients in public hospitals—

Senator WATERS: It's just all covered?

Ms Shakespeare : they receive services free of charge.

Senator WATERS: So the MBS is only relevant for the private hospitals once there's been out-of-pocket—

Ms Shakespeare : Or private patients in public hospitals.

Senator WATERS: I understand. Thank you. You've taken on notice the information you could provide me about how public hospital funding could perhaps be boosted or have something else done to it to facilitate free access. Are there any other sorts of policy interventions, whether they be funding or whether they just be pure policy, that the Commonwealth could now have an elevated role in?

Ms Shakespeare : The Commonwealth also funds, through the Pharmaceutical Benefits Scheme, access to medicines for medical termination of pregnancy.

Senator WATERS: RU486 and the like?

Ms Shakespeare : That's right. That's covered under PBS.

Senator WATERS: Again, does anything need to change, or is it merely that, now the Queensland barrier has been removed, they could now be more readily used? You tell me.

Ms Shakespeare : Yes. Those benefits are available to anybody in Australia, including in Queensland, if there are no legal problems there.

Senator WATERS: Okay.

Ms Edwards : The hospitals team has gone away, but I'm still here. I can answer a little bit of the questioning.

Senator WATERS: Thank you.

Ms Edwards : The way hospital funding works, generally speaking, is that states and territories decide what procedures are to happen in a public hospital and have complete control about how that's managed. Then, under the National Health Reform Agreement, the Commonwealth provides a contribution to the costs of those services. Assuming a public hospital provides the procedure, it would be included in the calculations. The Commonwealth, speaking generally, provides an amount which is made up of the amount that it paid for the previous year plus 45 per cent for efficient growth—so for the growth in procedure. Say there are a large number more terminations than there had been the previous year. Then we would pay 45 per cent of what's calculated to be the efficient price of those procedures in the following year.

Senator WATERS: How does the efficient price does that differ from the actual price?

Ms Edwards : The Independent Hospital Pricing Authority determines what's the price worked out in a mathematical, actuarial way.

Senator WATERS: To stop rorting, for example?

Ms Edwards : That's an independent body, and that's the basis on which we move forward for the price of that particular procedure. It's rolled up. It's a very complicated mathematical procedure. Generally speaking, if a procedure happens in a public hospital, it's factored into the overall funding, and the Commonwealth provides a contribution to that. But the decision to provide a particular service in a particular hospital—

Senator WATERS: It sits with the states?

Ms Edwards : It is entirely a matter for the states, yes.

Senator WATERS: Should I understand that what you're saying is that the Commonwealth wouldn't need to change the funding arrangements, because they have already catered for it once the state listed it as a procedure that would be done?

Ms Edwards : If they are doing in the public hospital, yes, we will provide a contribution.

Senator WATERS: So that funding lift would effectively automatically flow once the states added that to the list?

Ms Edwards : Correct. We wouldn't pay for the whole of the growth, but it's a contribution to that, so the funding arrangements would change. If there are more procedures provided, the formula would apply: that we would pay 45 per cent of the growth.

Senator WATERS: Okay. I know there's been some history about where the line is drawn and whether it's 45 or more, so I won't go over that. I'll just ask Richard. I'm sure he can tell me the answer to that. Are there any plans to deliver national commitments to better sexual and reproductive health outcomes for rural and regional communities—in particular for women's reproductive options? I'm not sure who's best to answer that.

Ms Shakespeare : Certainly any services that are available under the Medicare Benefits Schedule are available to everybody.

Senator WATERS: Irrespective of location?

Ms Shakespeare : Regardless of which location they're in throughout Australia. So there are certainly services, but boosting access to services would probably be something that would fall under one of our other programs, possibly in population health.

Senator WATERS: Can you shed any light on that?

Ms Edwards : Generally speaking, there is a priority for everyone to make sure people have services to the greatest extent that they can in the place they live and to expand services in remote and regional areas. We have lots of activity happening across the department, in various ways, to try to boost that—for example, in the workforce area, in terms of trying to have additional doctors and nurses in remote and rural areas.

Senator WATERS: Is there anything specifically on women's reproductive health?

Ms Shakespeare : Could we take that on notice. There might be other people in the department as well working on that.

Senator WATERS: That would be great. I'd like to learn a bit more at this stage.

Ms Edwards : It's probably across the department too, in various places.

Prof. Murphy : It's probably worth pointing out that the big advance recently has been the advent of medical abortion. Medical abortions are mostly prescribed by general practitioners, and obviously they're available across the whole country. At less than nine weeks, you can do a medical abortion with the pharmaceutical benefit that we cover. That's significantly improved access, as surgical abortion services are generally more limited in certain facilities.

Senator WATERS: Can you just clarify for me: are those PBS rebates up to nine weeks still available where the Criminal Code is still in play, namely New South Wales and, technically, South Australia as well? My understanding was no, but, if I'm wrong, that's great news.

Ms Shakespeare : My only advice on the position in New South Wales is termination is generally considered lawful if performed to prevent serious danger to the woman's mental and physical health. In those circumstances, I think medical or surgical termination wouldn't be prevented by state law.

Senator WATERS: There's a long and complex history behind that phrase. That was what was in play in Queensland too. It was so uncertain it had a chilling effect on doctors' comfort to provide these services. That all spiralled and there was generally a lack of access. Thank you for that, but I'm not satisfied that's sufficient. Certainly, we still want it decriminalised across the country. Maybe one of you could provide me with a bit more information on notice about that point about PBS availability and how that interacts with the need for a doctor to certify that the women's mental health or physical health is at risk from continuing the pregnancy?

Ms Shakespeare : Certainly. I've only got numbers of scripts at a national level here.

Senator WATERS: Yes, they're useful.

Ms Shakespeare : But if we take it on notice, we can break that down into states for you, I think.

Senator WATERS: Thank you. Could you give me those national figures as well?

Ms Shakespeare : For 2017-18 there were 20,494 patients who accessed the drugs mifepristone and misoprostol.

Senator WATERS: Now that we've segued to PBS, what's the status of efforts to list those long-acting reversible contraceptive insertions on the PBS?

Ms Shakespeare : I'm not sure. We'll have to take that on notice.

Senator WATERS: Thank you. I think I'm almost done. Can I ask about Medicare data collection on terminations? Perhaps it's just been peculiar to Queensland because of our Criminal Code status, but my understanding is the data has not been very fulsomely collected. Is that case nationally? Can you tell me about the rules to capture—

Ms Shakespeare : The issue with Medicare data is that it reflects the item and we do not know whether the service is provided for a termination of pregnancy or because a woman has miscarried. The item is evacuation of the contents of the gravid uterus.

Senator WATERS: So it could be a D&C or for any other sort of reason.

Ms Shakespeare : We certainly have data about the numbers of times that service is provided and claimed, but we don't have any breakdown of the reason for the evacuation.

Senator WATERS: Are there moves to consider separating out the item to desired—well, they're all desired—terminations versus other evacuations? I don't know what the appropriate terminology is, I'm sorry. Is there a move to make it more granular, so that you know what is a termination by choice versus, sadly, a termination not by choice?

Ms Shakespeare : We don't have any plans at the moment. The medical procedure itself is the same.

Senator WATERS: It's the same, presumably. I think that's it for me. Thank you very much. You have been very helpful.

Senator SINGH: Thank you. We're on program 4.1. Is that correct?


Senator SINGH: To follow-on, I understand access to termination services is a state based issue, but you'd be very aware of what's occurred in Tasmania with a lack of access to terminations services. Today it was revealed that the Tasmanian health minister has failed to meet his own deadline of access to those termination services by October, which is now. Has the department in any way been in consultation or communication with the Tasmanian government in relation to this crisis?

Prof. Murphy : No.

Senator SINGH: All right. I want to move on and asked questions to AIHW, mainly about out-of-pocket costs in relation to Medicare services, particularly about cost barriers to care. For the record, how many people have been delayed or avoided GP care due to cost, in the most recent financial year, which I think you would be able to provide, 2016-17?

Mr Sandison : That's correct. It was eight per cent of the people that were involved using the patient experience survey who said that they'd put off and delayed interaction with a health service because of cost.

Senator SINGH: That's eight per cent of 15½ year-olds—

Mr Sandison : I will check on the exact numbers. I have just got the percentages down for the figures here. I can table a copy of the report?

Senator SINGH: That would be fantastic, yes. That's GP care?

Mr Sandison : Yes. We split it up between five different groupings, so GPs, specialists and so on. We will get a clean copy, mine's got a lot of notes—

Senator SINGH: The eight per cent, is that GP care?

Mr Sandison : That's across all of them. Then the survey breaks some of the information up across specialists, GPs and so on. The work we did on the out-of-pocket was to bring together Medicare related services, so it's only one part of the out-of-pocket expenses, and provide a break-up. There were geography related issues in there, because the primary focus of these reports is to look not just at national figures, but break-up by primary health care levels. Then the survey work that we did took data from the ABS. Again, it is on the website, but we can provide a copy of the report to the committee.

Senator SINGH: I don't know if the breakdown is on the website. I'm interested in GP care and specialist care, and the percentages of each of those, not just the overall—

Mr Sandison : I think the information we had was how many people delayed specialists and GPs. The overall figure was the eight per cent. We have break-up by specialist and GPs, diagnostic imaging and pathology in the report. So rather than read them out and so on I can just—

Senator SINGH: And you're able to table that now? That'd be great. What about figures varying by remoteness, is that in the report as well?

Mr Sandison : It is. It's in there by the 31 primary healthcare networks and the 333 statistical areas that we break the data up by.

Senator SINGH: Those figures are based on sort of modelling assumptions about 15-plus year-olds needing certain types of care.

Mr Sandison : It's not on modelling; it's on the survey. The out-of-pocket expenses had two elements to it. We used the Medicare dataset, the MBS dataset. That's straight from the data. That was for the work about out-of-pocket expenses itself. Then the survey is the ABS survey that is done, and that was picking up the information from—obviously, as a survey it's not the whole population and it's not modelling—the data taken from the survey.

Senator SINGH: Can you breakdown the proportion of 15-plus year-olds who needed GP care, specialist care and pathology?

Mr Sandison : Again, rather than reading through all of the report, the information has it there. And then we are more than ready to provide a briefing on any additional information, because a lot of it might not necessarily be in this report, but in other reports, and equally some of it will be in other survey data from the Australian Bureau of Statistics.

Senator SINGH: Alright. Thank you very much, Mr Sandison.

Senator WATT: We have other 4.1 questions. I think Senator Griff might have some questions for—

Senator GRIFF: Yes. Earlier, I'm not sure, Mr Sandison, whether you caught—

Mr Sandison : I have. MyHospital's website and the 17 indicators. Basically the MyHospital's website is looked after by the Institute of Health and Welfare. It moved to us couple of years ago. Prior to that it was with the National Health Performance Authority. The 17 indicators were determined about eight years ago, as you said this morning, and out of those seven are currently reported on at hospital level—noting there are over 1,000 hospitals in Australia, so that provides a greater consolidation—

Senator GRIFF: They're primarily public—

Mr Sandison : Yes, against those seven. Another one is reported on at state and territory level, because it's primarily their data anyway, and the most accurate reporting is straight from them. Three of them were reviewed and recommended for deletion. The statement about underdevelopment is probably incorrect. There was no formal decision not to take them forward, and that was because of the absence of data and the relevance of the indicators. One of the key things is that, only over the last couple of years, data integration has become far more available and you can only assess the data for some of those indicators using data integration—that is, using different data sets and bringing them together. Two years ago, there was a review of the framework. All of this is done under the performance and accountability framework. That's an agreement through COAG across the Australian health ministers. Two years ago, there was a decision to review the whole thing and have a new framework. It's on the COAG website. Again, we can point you to the website, Senator, although I have got a copy of the new Australian Health Performance Framework that I can table.

Senator GRIFF: Thank you.

Mr Sandison : It is from that that the new indicators are going to be developed with all jurisdictions and the Commonwealth, with the institute providing the support to look at the indicators that should be established that are measurable and are relevant to the key areas of health now rather than eight years ago.

Senator GRIFF: So the COAG Health Council August meeting will tie into this? That is what you're saying?

Mr Sandison : I'm not sure whether it's the August meeting. The framework was actually determined late last year. The institute, it's been agreed, has joined the—

Senator GRIFF: That was about disclosure of hospital and clinician performance across also private and public?

Mr Sandison : I won't speak on behalf of the department, but all of this tied into some of the work that was mentioned this morning about the enhancement of data as part of the reform agreements. This is one part of that. The institute's role is to support both AHMAC as well as the department.

Senator GRIFF: Could you provide on notice the status of the work on this?

Mr Sandison : On the new framework?

Senator GRIFF: Yes.

Mr Sandison : Certainly, Senator.

CHAIR: We will break for 15 minutes.

Senator WATT: I think Senator Griff was just saying he doesn't need AIHW to stay, and we are done as well with them.

Senator SINGH: They can leave.

Senator WATT: Thanks.

Proceedings suspended from 21:17 to 21:30

Senator GRIFF: I would like to just kick off by asking a question as a result of some concerns of some specialists in a state that have alerted me to the fact that there are some neurosurgeons demanding commissions from anaesthetists as part of referring work to them, although it appears that doctors paying each other kickbacks in exchange for referrals may be in breach of the relevant ethical codes. Is this type of conduct actually lawful under current legislation? It's an interesting question, but this is definitely happening, so I would be interested in the department's view on where this sits.

Ms Shakespeare : I'm fairly certain there are generally criminal laws around bribery that are not under health legislation but that might apply here if somebody is paying bribes to another person in order to obtain a financial benefit.

Senator GRIFF: So that wouldn't be an issue with anything whatsoever to do with the department?

Ms Shakespeare : With the claiming of Medicare benefits, we have Health portfolio legislation which certainly relates to things like inappropriate claims. But, where we have fraudulent claims—

Senator GRIFF: But commissions wouldn't fall under that, of course.

Ms Shakespeare : Fraudulent claims, for instance, are a criminal law matter, and I think bribes are probably going to fall into the same bucket.

Senator GRIFF: All right. We will take that a little further.

Senator Scullion: You might consider—because these are matters obviously not known to us—that there is the compliance. You can put the details of that, if you would like, in camera to the department, and they can perhaps get back to you. They may be unable, in such broad terms, to give you the answer that you require, but they could look in more detail at that and discern whether it's criminal behaviour. But that's a matter for you.

Senator GRIFF: I think it would be worthwhile. We will speak separately to you about that information, because, as the minister said, I think it would be worth you being aware of this.

Senator Scullion: Indeed. It sounds like we would be.

Ms Shakespeare : Thank you, Senator.

Senator GRIFF: I have a few questions about MBS item No. 16590, which is the antenatal planning and management fee. I note it is listed under the private health insurance reforms clinical categories. I have received reports that some obstetricians are charging as much as $10,000 for this item for a woman undergoing pregnancy through the private health system, and I think the Medicare approved fee for this item is $372. Are you aware of this?

Prof. Murphy : This is an issue that's come up in my Ministerial Advisory Committee on Out-of-Pocket Costs. I think the average fee was a bit over $4,000 for that item, but you're right. Some fees are up to $10,000.

Senator GRIFF: Some are up to $10,000.

Prof. Murphy : This has nothing to do with admitted fees. This is a non-admitted Medicare item, and the obstetricians have, as a matter of practice, exercised their view that the collective MBS reimbursements for management of a pregnancy are, in their view, inadequate. So they have all put a large fee on this particular item number. It has come up as a matter of quite significant concern. Perhaps its background was when the original Medicare safety nets were introduced. A lot of these obstetricians increased their fees, and the patients weren't paying for it.

Senator GRIFF: It's pretty substantial—$10,000.

Prof. Murphy : Then the safety net was capped, and they've kept their fees at that level. There is some evidence that those fees are now starting to drop, because private obstetrics is falling. There is significant data to suggest that a lot of couples with private health insurance are now choosing to go to the public sector, and a number of private hospitals have reported significant decline in private bookings, and many of the private obstetricians are finding that their workload's drying up. So market pressure is finally having some effect and we're starting to see—certainly in some jurisdictions like Brisbane—that the fees have dropped dramatically for the younger group. But the College of Obstetricians and Gynaecologists are very worried about this, and separately they've been doing some work with the private insurers and the department to look at what can be done to make the out-of-pocket experience for a pregnant couple less painful. It's certainly a significant issue, and it possibly is an issue leading to people not taking out private health insurance, because planned pregnancy was one of the reasons that a lot of couples did take up private health insurance. It is a significant issue. Market forces will have some effect, and it's certainly one of the topics we've looked at in our out-of-pocket costs committee.

Senator GRIFF: Just on that, at the COAG Health Council meeting in August it was agreed that the Commonwealth would release a detailed report on the activity of the Ministerial Advisory Committee on Out-of-Pocket Costs before the next COAG meeting, but, according to the notes of the October COAG Health Council meeting, the Commonwealth has still not provided a report.

Prof. Murphy : The report is not yet finalised. We had to clear it with our advisory committee, who are mostly busy medical leaders, and we had to get them together.

Senator GRIFF: So it's ready to release?

Prof. Murphy : It's finally being drafted. We had a meeting last Friday with the committee, and there are a number of amendments that will be made to it. Then it has to be delivered to the minister, because it's a ministerial advisory committee, and it will be up to the minister. He made the commitment at the COAG Health Council that he would make the information available, but it's up to him to receive the report first and decide when and how to release it.

Senator GRIFF: So you would imagine that that will be fairly soon, in the next month.

Prof. Murphy : That's up to the minister, but I think he's very keen to progress this issue.

Senator GRIFF: Have you examined out of pocket costs being charged across different specialities?

Prof. Murphy : Yes, we have some data on that. There are three areas that we've looked at. One is admitted out-of-pocket costs, and I think we've found that orthopaedics, neurosurgery and neurology are particularly featured, largely in anecdotal reports but also from some data that we've gained from various sources. The other particular area is private cancer, not so much because the individual fees are very large but because there is often a sequence of surgery, diagnostic imaging, radiotherapy and chemotherapy. If it's all done in the private sector, the cumulative costs can be significant. Then there are people with chronic disease who are having ambulatory care in the private sector with private specialist visits. It might only have a modest out-of-pocket cost of $40 or $50, but, if you're coming every fortnight and you're on a fixed income, that can be burdensome. The other issue that we've been very closely working on is the practice by a small number of specialists of charging hidden fees, such as booking or administration fees that are not disclosed to Medicare or the insurer. I have to say that the leadership of the medical profession is right behind doing something significant about this.

Senator GRIFF: Thank you. I'll do the rest on notice.

Senator SINGH: I want to go back to the Medicare freeze. In particular, I want to ask the department: is it correct that there are 100 GP items that are frozen until July 2020?

Ms Shakespeare : Medicare indexation commenced from 1 July last year on some items. GP bulk-billing items were indexed last year. There were a range of other GP consultation items that were indexed on 1 July this year. There are, I think, more specialist consultations as well. More specialist procedures will be indexed next year, and each year the indexation from the previous year's items continues. So there are many items that have been indexed, and some have been over two years now.

Senator SINGH: I'm just going on that Department of Health list, which has 1 July 2020 GP services, and it lists them all. That's why I'm asking how many items we're talking about.

Ms Shakespeare : I think we'd probably have to count them from that list.

Senator SINGH: We'll be here a while if that's the case! Do you accept that there will be greater upwards pressure on out-of-pocket costs for these items?

Ms Shakespeare : The reason that the government has now invested $1.5 billion in indexing Medicare items is to try and put downward pressure on out-of-pocket costs.

Senator SINGH: But I'm talking about the items that have been reindexed.

Ms Shakespeare : There is a commitment that those items will be indexed. It will be in a staged way—

Senator SINGH: In the meantime, will there be greater upwards pressure on out-of-pocket costs?

Ms Shakespeare : The other thing we can look at here is bulk-billing rates, which are continuing to increase.

Senator SINGH: I'm not asking about bulk-billing rates; I'm asking about these particular items and whether or not there will be greater upwards pressure on out-of-pocket costs than on the items that have been reindexed.

Ms Shakespeare : Competition between services and practices also has an impact on out-of-pocket costs. It's not just that these particular items haven't been indexed. I think, if we were to look at some of them, the ones from 2020 are targeted diagnostic imaging items.

Senator SINGH: Well, let's look at some of them. That's a good idea. Go on.

Ms Shakespeare : Some of the other GP services—we probably could get you bulk-billing statistics to look at those areas. Generally, more services are being provided at no cost to the patient, because bulk-billing rates are continuing to increase.

Senator SINGH: Okay. That doesn't really answer my question, Ms Shakespeare, but let's delve into it to try and get an answer. Let's look at those items that I referred to in the table. One of the items is item No. 2713, for mental health consultations. GPs have raised concerns that freezing this item while reindexing health items will either provide patients a lower rebate for mental health consultations than for standard physical consultations or force GPs to bill standard consultations, which will result in data inaccuracies regarding mental health prevalence and service provision. Which one do you expect will happen out of that scenario to do with that particular freezing of that item?

Ms Shakespeare : I think you're asking us to speculate on what will happen with services for an MBS item.

Senator SINGH: Item 2713 is a standard mental health consultation—is that correct?

Mr M Ryan : Yes, that is correct, that is a mental health services item.

Senator SINGH: My question, which I am happy to repeat, was in relation to the freezing of that item. The freezing factor of that item means that it will either provide patients with a lower rebate, obviously, for mental health consultations than for standard consultations or it will force GPs to bill it as a standard consultation, which will result in a data inaccuracy as compared to what it actually was. Which do you think is going to happen in that situation?

Ms Shakespeare : I'm not sure we can speculate on that. Perhaps that would be a question for GPs providing services. It's really a clinical judgement as to which MBS item you feel is appropriate to bill for the service that you've provided to a patient.

Mr M Ryan : If I could just add to that: the benefit for that item is $71.70, which is a higher rebate than a standard GP consultation, even after the indexation that has been applied to it. I would be surprised if GPs would change to a lower rebated item for this particular service.

Senator SINGH: Thank you.

Senator WATT: We think that's it for us for 4.1. We do have some for 4.2, Hearing Services.


Senator SINGH: Does the government still have plans to privatise Australian Hearing?

Senator WATT: It's probably something for the minister, really, isn't it?

Senator Scullion: I'm not aware of that, Senator. I'll have to ask if my department can provide me some advice on that matter.

Dr Studdert : My colleague Mr Martin can answer that question.

Mr Martin : My recollection is that there was an announcement in the 2017-18 budget that there were no plans for the government to privatise Australian Hearing, although that agency sits within the Human Services portfolio, so more detailed questions might need to be directed to them.

Senator SINGH: Minister, is that the case? Will the government commit to Australian Hearing remaining in government ownership in the next term of government, your own government?

Senator Scullion: My understanding is that the department has just provided you with a reflection of what was announced at the last budget. I'll take that on notice. If the answer to that is different, I'll provide a different answer.

Senator SINGH: If that's the case, Mr Martin, why then, in its response to the inquiry into hearing health and wellbeing in Australia, did the government simply note the committee's recommendation that the committee supports the decision not to privatise Australian Hearing and recommends that Australian Hearing be retained in government ownership?

Senator Scullion: Well, noted is often that we note that that is a part of the report. It's a pretty neutral response, because no responses have been required—

Senator SINGH: But noted gives no guarantee as to whether or not—

Senator Scullion: Well, no, but it's not—

Senator SINGH: It doesn't really mean a lot, to be honest; it just means you've read it.

Senator Scullion: Noted, by convention, means a particular thing. It's ambivalent on that. I have a number of things as minister. I note it, simply that it has been a part of the report. We noted the report, but I don't think that can mean something one way or the other. What is more applicable about this matter is the statement during the budget that my department just referred to, that we had no intention of privatising Australian Hearing.

Senator SINGH: Okay.

Senator WATT: On that basis, will the government commit to Australian Hearing remaining in government ownership in the next term of government?

Senator Scullion: As I've just indicated, my belief is that that has already been the case. As I've said, I'll take that on notice. If it's different, I'll provide you with a different answer.

Senator WATT: Okay. That is it for 4.2, but we have 4.3, on the PBS.


Senator WATT: I want to ask about a question on notice from the last estimates round, SQ18-000919, which I have a copy of if needed. It talks about the process for listing a drug, basically. The department's KPI:

… includes the percentage of new medicines recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) that are listed on the Pharmaceutical Benefits Scheme within six months of agreement of budget impact and price.

In 2015-16, eight per cent of medicines were delayed beyond this KPI, and you have said that equates to just one medicine, which is—I'm not going to get this pronunciation right—bendamustine, which is a chemotherapy medicine. Does that mean the government only listed 13 new medicines in 2016-17, if one is eight per cent?

Ms Shakespeare : The KPI refers to units and we count new molecules.

Senator WATT: New molecules? So it might be that there are other drugs that were listed that weren't new molecules?

Ms Shakespeare : Yes. There are many, many listings which are new indications, changes to indications. These might all have budget impacts or not. So, yes, but those numbers are counting new molecules listed.

Senator WATT: Okay. So similarly, 15 per cent of medicines were delayed beyond the KPI in 2016-17, and you say that it equates to four medicines. Does that mean that only 27 new medicines were listed in 2016-17, or is it the same issue?

Ms Shakespeare : New drugs, new molecules.

Senator WATT: Yes, new molecules. So, again, more listings, but only 27 of them were, as you put it, new molecules.

Ms Shakespeare : That's correct.

Senator WATT: Right. Are you confident to stand behind the government's claims that it lists one new medicine a day on the PBS?

Ms Shakespeare : Those are new and amended listings, yes.

Senator WATT: 'New and amended listings'? What's the distinction between a new and an amended listing?

Ms Shakespeare : Some examples I just provided before, so we might have new indications for an existing listed molecule or medicine.

Senator WATT: New indications?

Ms Shakespeare : Yes. There might be changes to restrictions so that a patient group that could only previously access a medicine after meeting particular restrictions, those restrictions are lifted. In some cases, those require new funding; in all cases, they require negotiation with the department around the listing.

Senator WATT: Okay. But anyone who's saying that they're listing one new medicine a day on the PBS, that's not entirely accurate.

Ms Shakespeare : Well for the patients who get access to the medicine, it's a new listing for them.

Senator WATT: Yes, but it's not as if it's going on the PBS for the first time.

Ms Shakespeare : Again, these are all changes to the PBS. Many of them have to go through the Pharmaceutical Benefits Advisory Committee; all of them have to be actioned by the department. They all involve public funding and effort.

Senator WATT: I acknowledge that—

Ms Shakespeare : And all result in benefits for patients.

Senator WATT: but there are new drugs, or new molecules, that are put on the list, and then there are others that are on the list, but amendments are made to them in terms of who can access them, the restrictions on them and that kind of thing.

Ms Shakespeare : Yes. For instance, a particular drug we've had several listings for, nivolumab, is an immunotherapy drug. It was listed for melanoma, then expanded to listings for non-small cell lung cancer, renal cell carcinoma. I think we've had squamous. That's not considered a new molecule because it's already on the PBS, but those are major new indications.

Senator WATT: Sure. Would it be more accurate to say there's one new or amended medicine a day listed on the PBS, rather than an entirely new one?

Ms Shakespeare : Yes, although there's not one new molecule listed on the PBS per day.

Senator WATT: Okay, thank you. Your annual report for 2017-18 shows that 12 per cent of new medicines weren't listed within the KPI. How many medicines was that, and what were they?

Ms Platona : There are two drugs, two new molecules, that are captured in that KPI. The first one is called glecaprevir.

Senator WATT: Would you mind spelling that? They're always difficult words, aren't they?

Ms Platona : Okay. The brand name is Maviret—M-a-v-i-r-e-t—and the sponsor is AbbVie. It's a hepatitis C medicine. That product was recommended by the PBAC at its November 2017 meeting; it was listed on the PBS on 1 August 2018. The second product, again with a brand name, is called Rekovelle—R-e-k-o-v-e-l-l-e. The sponsor is Ferring. It was recommended by the PBAC in November 2017; it was listed on 1 August 2018.

Senator WATT: Thank you. So they're the two—so 12 per cent equates to two in 2017-18.

Ms Platona : Out of a total of 17 brand new molecules.

Senator WATT: Okay. That's it for us for the PBS and 4.3. Have you got 4.3s?

Senator SIEWERT: No, but the questions I have that I want to ask and put on notice I thought were later on in 4, but they're apparently 4.1.

Senator WATT: I'm happy for you to ask them if we've got the right people still here.


Senator SIEWERT: It's about MRI allocation licences, which is 4.1.

Ms Beauchamp : Yes. We've got the right people here.

Senator SIEWERT: Okay, that would be great. And I apologise; I thought these were for elsewhere. I want to ask specifically about the situation in WA, and I'll try to be really quick because I know we're getting short of time. So there was more money allocated to the provision of MRIs. First off, I want to know what percentage of that money would be allocated to Western Australia—if that's known.

Ms Shakespeare : Senator, I don't think that will be known yet. Quite a large proportion of the additional funding is subject to a competitive invitation to apply process. That is open at the moment; it closes on 2 November.

Senator SIEWERT: So none of that money has been allocated? No extra licences have been granted yet?

Ms Shakespeare : The government has announced 10 new licences. One of those was in Kalgoorlie, which was announced some time ago now.

Senator SIEWERT: Which is actually why I ask, because I've understood, from what you've said, that there is a competitive process, but there have been 10 granted.

Ms Shakespeare : Yes, and from that initial 10, there's also another one in Western Australia, at St John of God hospital at Midland, which is an upgrade of a partial licence to a full licence.

Senator SIEWERT: Okay. Is there going to be a proportionality process used in the competitive tender process?

Ms Shakespeare : In the competitive process we are looking at a range of factors. There are mandatory criteria that have to be met to be eligible for an MRI licence in terms of the services that are provided at the facility. We are looking at areas of need on a primary health network basis. We've got a matrix to work out where are the areas of higher need. And we also need to look at where there are services that are ready to provide MRI, so there is equipment and things like that in place.

Senator SIEWERT: So 'area of need' presumably means waiting lists?

Ms Shakespeare : It's a combination of factors. Relative need of the primary health network is based on the number of Medicare eligible MRI units per 100,000 population existing; the time lag between specialist referral and rendering of the MRI service; distance to eligible machines, because there might be travelling distance involved; and availability of operational machines in a PHN.

Senator SIEWERT: So they're going to be allocated via the PHN?

Ms Shakespeare : Those are the factors we will be looking at to prioritise need in a primary health network area. We're also seeking the views of state and territory governments about where they think the greatest pressure is for MRI services.

Senator SIEWERT: In WA, I understand that the stats are down; we have fewer MRIs per head of population than other states. Does that get taken into consideration?

Ms Shakespeare : That will be picked up in the assessment at the PHN level, not necessarily the state level. Certainly if there are PHNs, which in WA, and I know that there are, that have lower access to MRI services at the moment, that will feature in the criteria.

Senator SIEWERT: And issues such as whether would you take into account whether an organisation or business that applies bulk bill or not?

Ms Shakespeare : That's certainly something we have asked for information on in the invitation to apply. I suppose in the situation where we had a couple of applications from the same PHN that were looking very similar otherwise, and one was offering commitment to bulk bill, that would be something that could be taken into account.

Senator SIEWERT: You said there are going to be competitive tenders. Do you also look at the number of operators in the field, and whether there is competition between the operators?

Ms Shakespeare : I think that is really something that gets picked up by us, looking at the existing number of services per head of population by PHN. So if there's already a fair amount of services there and competition there then that might reduce the relative area of need ranking.

Senator SIEWERT: I meant in terms of whether there's a limited pool that are operating the MRIs. Sorry if I wasn't clear.

Ms Shakespeare : I don't think that's a specific criteria that we've listed in the invitation to apply documentation, no.

Senator SIEWERT: When is the process completed for the decision-making in terms of allocation of the additional licences?

Mr Weiss : The invitation to apply closes on Friday 2 November, so next Friday. We'll be doing our assessment of the applications during November and providing advice to the minister, we hope, late November, early December.

Senator SIEWERT: So likely before Christmas?

Mr Weiss : Yes, with the intention that we would like machines to be operational by 1 March 2019.

Senator DEAN SMITH: I've got a question, just on the MRIs. In regards to Western Australia, in the country PHN or country WA PHN, which takes you from Kununurra in the north to Esperance in the south and everything outside of the Perth metropolitan area—so places like Karratha, Port Hedland, Derby, et cetera—how will you assess the need, for example, if a northern community in the far north of Western Australia makes a claim for an MRI? If a community in Karratha, for example, makes a claim for an MRI, but a community in the far south also makes a claim for an MRI, given that it's not a competitive market and the distances are extreme in the Australian context, how do you work that through?

Ms Shakespeare : It is difficult where you have very large geographic PHNs.

Senator DEAN SMITH: There wouldn't be many PHNs as large as country WA.

Ms Shakespeare : We are looking at distance to eligible machines as part of looking at the prioritisation criteria. The fact that there are already Medicare-eligible machines in places like Albany and Bunbury might mean that you try and get machines located elsewhere, so that patients have less distance to travel. But we haven't seen applications yet, and it's a bit hard to comment on—

Senator DEAN SMITH: Have you not even seen an application yet from Karratha?

Ms Shakespeare : I haven't seen any application.

Senator DEAN SMITH: Do you mean under the round that's just been announced, or generally?

Ms Shakespeare : The invitation to apply doesn't close until November so it's a bit hard for us to speculate on the locations of applications.

Senator DEAN SMITH: That's homework for me, not for you. Because I know that Senators Singh and Watt are generous people, I just want to go back to the MBS issue, just quickly, if I may? Did I hear in your evidence, Ms Shakespeare, that there had been 1,900 new or amended listings that have taken place since 2013? Did I hear you correctly?

Ms Shakespeare : I will just check that number for you...

Senator DEAN SMITH: I said 1,900, as in one nine zero zero—100 less than 2,000.

Ms Shakespeare : It is 1,920 new and amended listings.

Senator DEAN SMITH: So 1,920 new or amended listings have taken place since 2013. That's correct?

Ms Shakespeare : It is since October 2013.

Senator DEAN SMITH: Oh that's very specific—October 2013. So, that could translate, and maths was never my strength, to an average of around one per day?

Ms Shakespeare : Yes. So that's new and amended listings averaging 31 per month, approximately one per day.

Senator DEAN SMITH: Well done. Congratulations. That's remarkable.

Ms Shakespeare : We work very hard.

Senator DEAN SMITH: And thank you, Senator Singh and Senator Murray Watt for your generosity and allowing me to step back in time.

Senator WATT: Any time, Senator Smith. We're ready to move on to 4.4, private health insurance. The minister often points to Deloitte modelling, which I understand is from 2017, which he claims shows that the opposition's policies on private health insurance would result in a 16 per cent increase in premiums. Has the department provided any advice to the minister that would support this contention of a 16 per cent increase in premiums?

Mr Maskell-Knight : The minister released a fact sheet drawn on modelling that's been commissioned for PHMAC with the announcement of the private insurance reforms and that showed what Deloittes estimated the impact on premiums of different configurations of product categories would be. Fact sheet option 3 is described as essentially removing restrictions. So what it effectively amounts is to getting rid of the products which Senator Di Natale characterises as 'junk'. Were that to happen and were psychiatric care to be limited to silver and gold, and bronze not to have psychiatric care in it, then the impact on premiums would be about 15.7 per cent.

Senator WATT: Could you table that document for us, please?

Mr Maskell-Knight : It's the only copy I have.

Senator WATT: Yes, once you run off a copy. So that's a fact sheet that was provided?

Mr Maskell-Knight : It was put up on the department's website in October last year.

Senator WATT: And is the reduction of, I think you said, 15.7 per cent or around about 16 per cent, that about getting rid of so-called junk policies all together?

Mr Maskell-Knight : That's what it is effectively. So what it would mean is that bronze would offer unrestricted cover for a range of services, silver would also offer unrestricted cover and gold would offer comprehensive. So the usual characterisation of junk policies is that they have widespread restrictions.

Senator WATT: And that, of course, isn't the federal opposition's policy. The federal opposition's policy is to scrap the rebate for so-called junk policies as opposed to scrapping junk policies altogether, which I think was a government policy in the 2016 election. So has the department provided any advice to support the minister's contention that the opposition's policy to scrap the rebate for so-called junk policies would result in a 16 per cent increase in premiums?

Mr Maskell-Knight : At the moment, I believe the rebate on the lowest tier is 24 per cent. So removing the rebate from junk policies for people on the lowest tier of the rebate would result in a 33 per cent increase—24 per cent over 76 per cent.

Senator WATT: You would think that, if that were the case, the minister would be using the higher figure in what he's saying. Minister, is there a reason you're sort of giving Labor a half-price discount in the hyperbolic claims you're making about our policies?

Senator Scullion: One of the things I can say about the minister is that the reason he's so credible is that he sticks to the facts.

Senator WATT: Is that right?

Senator Scullion: Well, one of the reasons he's very nervous is that, last time you were in government, the premiums were actually raised by 28 per cent. I don't think there's any mucking about with those facts.

Senator WATT: I am not sure we want to get into a comparison on this.

Senator Scullion: The reason that he's nervous on behalf of Australians is that under the Rudd-Gillard-Rudd government there was a 28 per cent increase, and we can probably expect more of that, mate. But the direct answer to your question, I think, is that he's just a straightforward, honest bloke who's pretty factual. I don't think he's giving you any benefits at all.

Senator WATT: I'm not going to have a debate about that. How is it that premiums could rise by 16 per cent under a two per cent cap, which is, in fact, what the federal opposition has proposed?

Mr Maskell-Knight : I can't answer that.

Senator WATT: Is that because there just isn't an answer?

Mr Maskell-Knight : I think they are two mutually exclusive ideas. If you're going to remove the rebate from very low-cost policies, the cost of those policies is going to increase by the amount of the rebate divided by the premium that's left. So, if that is a policy, that will make the cost of premiums for those products increase by 33 per cent. Another policy is to cap premiums at a two per cent increase.

Senator WATT: Yes. Let's forget about which party it is. If a government were to cap premium increases at two per cent, it's actually not possible for them to go higher than that, is it? That's kind of the point of a cap.

Mr Maskell-Knight : It depends on how you implement the cap. There are 70,000 products out there. If you say you're going to impose a hard cap of two per cent on every one, there will be all sorts of peculiar and bizarre pricing issues going on, because insurers have to make commercial decisions about how they price products relative to the benefits that have been drawn down. If you say the two per cent cap is an average, that's a different issue.

Senator WATT: Okay. Minister, for the record, one of my colleagues has helpfully pointed out that premiums have increased by 27 per cent under your government, so I guess you win.

Senator Scullion: No, it's actually under yours that they have risen by 28 per cent.

Senator WATT: Well, you have a bit more to come next year, so maybe we'll have this debate then.

Senator Scullion: We'll be around for a few more years. Don't worry.

Senator WATT: It's good that one person in Australia thinks that. Let's move on to gold, silver, bronze and basic policies. The gold, silver, bronze and basic changes were due to take effect by April next year, but the minister has now given insurers an extra year to make the changes. Why did he announce this delay?

Ms Shakespeare : The transition to gold, silver, bronze and basic, and the clinical categories that underpin those tiers, will commence from 1 April next year. There will be a transition period of 12 months for all products to shift across to the new categorisation system.

Senator WATT: That extra year of transition is a relatively recent announcement from the minister, though, isn't it?

Ms Shakespeare : That was something that was included in the rules that were made earlier this month. We had a fairly extensive consultation period with all of the stakeholders interested in the private insurance reforms. That led to the development of the rules. We consulted heavily with stakeholders about how to best manage the transition to the new clinical categories and the gold, silver bronze and basic, and that was implemented through the rules.

Senator WATT: What effect will this one-year delay have on next year's premium price rises?

Mr Maskell-Knight : We don't believe it will have an impact either way.

Senator WATT: But I thought the entire rationale for having these gold, silver, bronze and basic policies was to keep premium rises down.

Mr Maskell-Knight : The package the minister announced in October last year had the tag line, 'Simpler, more affordable'. Gold, silver, bronze and basic was to address the simpler, not the more affordable.

Senator WATT: Right. I'm sure I have heard the minister and, I thought, people in this estimates committee previously argue that this was going to also help with affordability.

Ms Shakespeare : The categorisation system is really to reflect what's in the policies, not to reduce costs or increase costs. It's giving people information about what's currently covered by their policy or by a new policy if they decide they want to shift to a new policy in future. It is an information measure. There are certainly other parts of the reforms that are designed to have a downward impact on premiums, such as the reductions in prostheses benefits.

Senator WATT: But the introduction of gold, silver, bronze and basic policies is not expected to have any impact on premium rises?

Mr Maskell-Knight : Overall, no. As I said, insurers may need to make some adjustments to the content of the 70,000 or so distinct policies out there to ensure that they comply. Some individual products may have their premiums increased a bit as a result of that. Others may have some restricted cover removed and have their benefits decrease.

Ms Beauchamp : I think there were about 15 measures to dampen down any price increases or potential price increases, and the gold, silver, bronze, and basic was to make it much simpler for consumers to choose. Of course, that will commence rolling out on 1 April 2019. I think the minister announced that that implementation plan and transition plan is to finish no later than 1 April 2020.

Senator WATT: Have any insurers indicated they will implement gold, silver, bronze and basic policies immediately or before that one-year extension?

Mr Maskell-Knight : A number of insurers have indicated they plan on offering those products early in the new year.

Senator WATT: How many?

Mr Maskell-Knight : I would have—

Senator WATT: Or which ones?

Mr Maskell-Knight : I'm not sure it would be appropriate to say which ones, for commercial reasons. I can think of a number, but I would have to go back and check our records.

Senator Scullion: We might take that one on notice.

Senator WATT: Do you know what percentage of the market?

Mr Maskell-Knight : I would need to confirm that.

Senator WATT: If you can take that on notice. I understand Deloitte prepared a report regarding the gold, silver, bronze and basic policy change dated 28 June 2018. Have you got a copy of that here?

Ms Shakespeare : No.

Senator WATT: There's been a lot written about this report over recent weeks. Is there a reason that it hasn't been released publically?

Ms Shakespeare : It's modelling.

Senator WATT: It doesn't sound like there is an issue with tabling it, in that case. Can you please table a copy of that? I realise you haven't got it with you, but could you please table a copy of that?

Ms Beauchamp : We will take that on notice and see what status it's got.

Senator WATT: Okay, but I note that both officers shrugged their shoulders when I asked whether there was a reason that it couldn't be released publically.

Ms Beauchamp : Sorry, I'm just providing—

Senator WATT: Unfortunately, the Hansard doesn't pick up body language.

Ms Beauchamp : I'm just providing a formal response.

Senator Scullion: I'm sure that body language was indicating that they weren't absolutely accurate in providing the information why it couldn't be released. We'll have a look at those matters and we will give you the answer on notice.

Senator WATT: I always thought shrugging shoulders meant that it doesn't really matter.

Senator Scullion: It's late at night.

Mr Maskell-Knight : It's been a long day.

Senator WATT: A long week. What assurances have insurers provided that they will continue to offer products above the minimum requirements?

Mr Maskell-Knight : At the moment, as I think I've advised the committee before, the minimum requirement to offer a complying health insurance policy is to offer minimum default benefits for psychiatric, rehab and palliative care, yet just about every product in the market exceeds that minimum standard by a comprehensive margin. We see no reason insurers will suddenly decide that the only products they offer are the ones that meet the bare minimum.

Senator WATT: The Deloitte modelling, which we've been talking about, indicates that a substantial number of existing cheaper policies include coverage for procedures that will now only be available in gold policies. That includes joint replacements, spine surgery, cataract and eye lens surgery and chronic pain procedures. Doesn't it follow that some patients will be required to upgrade to gold and, therefore, pay more to maintain their current level of cover?

Mr Maskell-Knight : There was a Deloitte report that was released in the middle of last year. There was a table in there, which has been seized upon as the source of the argument you're making. We think that Deloitte mightn't have been as accurate with that as they needed to have been, perhaps. We've discussed that with them. Fortunately, it doesn't go into the rest of the modelling that they've done. That table says, for example, that hip and knee surgery is covered by 77 per cent of products at the basic level at the moment. They came up with that based on a survey. Once that number got a bit of currency, we decided we'd better go and check it. As of last week, there were 331 hospital policies available in New South Wales for singles, and they ranged in costs from $1,005 a year to $3,684 a year. If you say that basic to mid-range policies cost less than $2,000 a year, there were only four policies that offered unrestricted cover for all joints. There were 10 that offered unrestricted cover for joints, other than hips and knees. One policy covered hips, but not knees, and one covered restricted benefits for hips and knees. I think the view that there are lots of basic products covering high-cost procedures is not true.

Ms Shakespeare : There will be no requirement for a policy that was covering those services, which are categorised as basic, bronze or even silver, to remove that cover. It's not that you can only cover services that are under gold products. I think that's been in all of our material about this. Insurers can continue to provide additional services beyond the minimum clinical categories that have to be covered by each tier. Many of the insurers, I'm sure, will continue to cover the services that they do cover that are above the minimum tier requirements. They make those decisions based on what helps them sell products to their customer base.

Senator WATT: We'll leave it at that, thank you.


CHAIR: We'll move on to outcome 5.

Senator WATT: I will leave you in Senator Singh's capable hands. Enjoy the rest of the night.

CHAIR: Senator Singh.

Senator SINGH: My questions start in relation to silicosis, particularly how the Queensland government in September issued an urgent warning after 22 silicosis claims were lodged with WorkCover. I want to know where the status of the proposal for a national dust diseases register is at?

Prof. Murphy : The health ministers agreed at their most recent meeting to ask the Clinical Principal Committee of AHMAC—which I'm a member of—to consider developing a national dust diseases register. In the meantime, we have asked the relevant speciality groups, the College of Physicians and the Thoracic Society, to prepare an outline of what such a register would look like. That will be discussed at the next meeting of the clinical principal committee. We will then work that through the AHMAC process. It would need to be multijurisdictional support for such a register. It's likely that the WorkSafe authorities in each jurisdiction would support it. There are even indications that industry might support it as well. That's being progressed through the clinical principal committee of AHMAC.

Senator SINGH: Because it broadens it out from asbestos, obviously, to other dust diseases.

Prof. Murphy : Yes, this would basically be all occupational lung diseases that are due to inhaled products. It would include coalminers' lung, because that has become another issue that has re-emerged, particularly in Queensland recently.

Senator SINGH: It has, yes. Have any time frames been discussed on when such a thing might be operational?

Prof. Murphy : We haven't even had the first meeting of the clinical principal committee to discuss it, so I think it's just too early to say. But there's certainly great enthusiasm from the various medical groups to try to progress this as quickly as possible.

Senator SINGH: What would be the agency that would oversee that?

Prof. Murphy : That, again, would be determined. Often, clinical registries might be hosted—for example, Monash University in Melbourne hosts a number of clinical registries that are multijurisdictional. It could be something that the WorkSafe authorities collectively could host. But that's to be determined.

Senator SINGH: What about the funding of such a thing?

Prof. Murphy : Again, to be determined.

Senator SINGH: Set-up costs, running it and all of that?

Prof. Murphy : Again, to be determined. As I said, I think there is some suggestion that particularly the mining industry might be interested in providing some unconditional support, the Safe Work authorities in each jurisdiction would have an interest in it and, obviously, government might be called upon as well.

Senator SINGH: Okay. So, there's no time frame, and all the costs and all of these things are yet to be determined. It kind of leaves it a bit up in the air, doesn't it?

Prof. Murphy : No, I think it doesn't. The issue of accelerated silicosis—the dust diseases register is really something to prevent another issue like this happening or to keep track of mining. The silicosis from the cutting of engineered stone—there is a lot of very intense regulatory action happening now. All of the state WorkSafe authorities are—

Senator SINGH: But that's at the state level, isn't it?

Prof. Murphy : It's at state level, but the Commonwealth minister has committed to write to Safe Work Australia to ask them to ensure that all of the state regulatory authorities are taking this seriously and are clamping down on any potential—this is entirely preventable, just by wet cutting the stone and wearing appropriate respiratory support. The minister has also asked the federal minister to ask Safe Work Australia to review the current standards for crystalline silica in occupational exposure—they're being reviewed at the moment. They've also asked Safe Work Australia to explore whether some tracking of imports of this engineered stone could be used to make sure that we don't miss any site where this could be happening. It's a good thing there's been so much publicity. I think that, in those states where these cases have been seen, the local regulatory action is being intentionally driven now.

Senator SINGH: That's good to know, because we don't want another asbestos disease outburst.

Prof. Murphy : No.

Senator SINGH: But, obviously, there does need to be a bit more of a structure around, at the federal level, what happens and when it happens.

Prof. Murphy : Sure. The dust diseases register would be—if something else like this happened in the future, we might pick it up a lot earlier, I think.

Senator SINGH: Has the national industrial chemicals regulator made any recommendations around the handling of silica dust?

Prof. Murphy : I don't think an engineered piece of stone would fit under the criteria. I could take that on notice, but I wouldn't have thought that that would be classified as an industrial chemical.

Senator SINGH: All right, take that on notice. Has any medical research into silicosis been carried out in Australia?

Prof. Murphy : I'm not aware of any. Certainly the original reports came from overseas. There are certainly a lot of studies being done by the various respiratory physicians who have seen these patients. But it probably isn't something that needs a lot of medical research, other than perhaps to try and improve treatment options, because they are pretty grim at the moment—basically it is lung transplantation if you have advanced disease. But we understand very clearly the cause of the disease and how to prevent it, and we don't really need more research to tell us that.

Senator SINGH: Alright. There's a lot of follow-up to do there—

Prof. Murphy : There's a lot of action—

Senator SINGH: but at least it's on the radar and, obviously, it's on the state government's radar, but we need to see how the Commonwealth will advance that. I have another 5.2 issue, Chair. I want to talk about strawberry contamination.

Ms Beauchamp : The strawberry people have gone because it was under item 2.4. But, obviously, we can take it on notice. But the food people—

Senator SINGH: Alright. I'll have to put the strawberries on notice. We all know those that put pins in them are certainly on notice! I'll just quickly finish my 5.2 questions, before I go to Senator Siewert, on PFAS. Particularly for you, Professor Murphy, do you have any concerns about the reliability of the national PFAS blood sampling program?

Prof. Murphy : No. I think there was a report recently about an error in a blood test that was taken by someone who had one test properly in the government-run program and had another test done and got a different result. In fact, the National Measurement Institute acknowledged that that was an isolated human error in that particular estimation. Ms Appleyard can provide more information on that.

I think it's really important that these labs that are doing these tests are properly NATA accredited and have all the right quality controls, but it's also really important to know that we have no idea what the meaning of these bloods test are. They don't have a clear clinical significance. We don't know what is a safe level. All we know is what a blood test can tell us about one's relative level compared to the rest of the population. The value to us of these blood test is actually to associate them with the ANU epidemiology study, and other research programs, and to follow things over time. But a particular blood test that might be high or low is of no clinical proven significance at this time. Ms Appleyard can talk about the particular incident if you like.

Ms Appleyard : As you're aware, there was a report in The Sydney Morning Herald about a week ago questioning the reliability of PFAS blood testing. As Professor—

Senator SINGH: By Sonic Healthcare.

Ms Appleyard : By Sonic Healthcare, that's right. As Professor Murphy mentioned, all chemical analyses do have a degree of measurement uncertainty. Two tests taken on any one day from the same sample can give a different result varying to up to around 20 per cent that would be normal. In this case, the one that the article was reporting, of course, was greater than 20 per cent difference. The reason for that greater difference was that there was actually a mistake by the National Measurement Institute, who reported that result. They were reporting on behalf of Laverty Pathology. The service that we use is Sullivan Nicolaides Pathology, which is from Sonic Healthcare. Obviously, there is some confidentiality around the actual test and the figure, but the National Measurement Institute has advised that this error occurred. It was in relation to the perfluorohexane sulphonate result in question, and it was the one that was reported in the media. The laboratory have corrected their error and they have advised the patient. So—

Senator SINGH: And the media?

Ms Appleyard : I can tell you that we have responded to media queries in relation to this, Senator Singh. That's correct.

Senator SINGH: That would obviously be a good idea, considering people are concerned. Finally, on lyme disease, you know that there was a Senate inquiry. Set out in recommendation 5 of that inquiry's report into it, it said that the department has now conducted two forums, one with state and territory medical officials and one with patients, and reports have been produced for each forum. I'm advised that there are no consequential actions set out from that. Will the department report on what action is underway to address each of the key priorities set out in the patient forum report?

Prof. Murphy : Yes, and that's certainly the plan. Those two reports would be initially discussed at the Clinical Principal Committee of AHMAC, which is the principal national body that looks at such clinical issues so that we can plan the development of a clinical pathway, including a multidisciplinary care approach. That was one of the key outcomes of both of those forums. We don't want to jump down a diagnostic rabbit hole without fully assessing these people with genuine multicomplex symptoms. That will be discussed at the Clinical Principal Committee and we will seek their advice to do that.

Senator SINGH: When will that happen?

Prof. Murphy : Again, at the next meeting of the Clinical Principal Committee. I think it's early next year—yes, at the moment. The other important thing to note about that is that we can't do this on our own. The state and territory health services are a very important part, and probably some of the best services that have been set up have been in state and territory health services where they have the capacity to set up multidisciplinary clinics. Prior to the meeting with the Clinical Principal Committee, we were engaging, through the Health Protection Principal Committee, with the Chief Health Officer, asking for their support to try to develop such clinic programs in each jurisdiction. The other mode of action that came out of those forums was that there needed to be a lot more education for health professionals generally. We're working through the Health Protection Principal Committee to develop some education programs around diagnosis and proper assessment of these patients. We know that tick bites can cause some proven diseases. There's no clear evidence that it's causing this symptom complex, but we feel, and the patient groups feel very strongly, that we should be promoting tick bite awareness and tick bite first aid. That's another educational strategy.

Senator SINGH: I flicked one out of my hair the other day. Hopefully it didn't go any further. Well, it flicked out. I have other lyme disease questions, but I'll put them on notice and will pass to Senator Siewert.

Senator SIEWERT: This is where I wanted to go. I want to go specifically to the issue around the report, which we discussed last time, out of the patient group forum for debilitating syndrome complexes attributed to ticks. My recollection of what we talked about last time is that the report was imminent in terms of reporting back to participants.

Prof. Murphy : At the last estimates, I think we'd only had the health professionals forum. I don't think we had had the patient forum.

Senator SIEWERT: Yes, I think you had.

Dr Lum : Excuse me, Senator, are you referring to the NRL evaluation of the tests serological tests performed in Australia?

Senator SIEWERT: No, I was talking about the patient group forum. I thought that had been held as well.

Ms Appleyard : There were two patient group forums. One had been conducted by estimates last time. There was a subsequent one in July and that was in Sydney, and that was the larger patient group forum. The reports from both of those forums are on the website. I think that's right.

Senator SIEWERT: From both forums?

Ms Appleyard : That's correct, yes.

Senator SIEWERT: When did the second one go up?

Ms Appleyard : It was probably at least within the last month or so, I would have thought. I can find that out for you and take it on notice if you're keen on knowing the date.

Senator SIEWERT: Yes, if you could, that would be appreciated. Would you be able to provide me with the link to that?

Ms Appleyard : Yes. It went up this month, I'm advised.

Senator SIEWERT: In other words, just fairly recently?

Ms Appleyard : Yes, fairly recently.

Senator SIEWERT: Have the participants been informed of it actually going up on the website?

Ms Appleyard : Yes, they have been informed. We have an email list and they communicate with us quite frequently, and we were quite proactive in letting them know it had gone up. Obviously they're very keen to see it.

Senator SIEWERT: You just touched on a list. Does that mean that a group broader than the participants of the forum were actually also contacted to let them know the report is available?

Ms Appleyard : I know at least the participants of the forum—and there were quite a number—were advised. As to whether it was any broader than that—all of the stakeholders that were on our list were informed. Some of those participated in person at the forum, but, as you'll well appreciate, some of them were too unwell to come to the forum and participated either by teleconference or videoconference facilities. So we were able to advise them when the report was available.

Prof. Murphy : I would suspect that, since most of the groups were represented, that information will have been disseminated.

Senator SIEWERT: Thank you.

CHAIR: I think we are done. Thank you, everybody, for your contribution today. We will look forward to seeing you another time.

Committee adjourned at 22:42


Following the hearing, the Community Affairs Legislation Committee received this statement from the Secretary of the Department of H ealth, Ms Glenys Beauchamp PSM—

Appearing at senate estimates this week I omitted to mention it was the final attendance before senate estimates for Ms Rae Lamb, the Aged Care Complaints Commissioner and Mr Nick Ryan, the Chief Executive Officer of the Australian Aged Care Quality Agency as these two agencies will be merged into a new organisation on 1 January 2019. They will continue in their current roles until this time.

Ms Lamb and Mr Ryan have made significant contributions to improving the quality and safety of aged care services in Australia - they both have very tough jobs.

I would appreciate if the Hansard could recognise their contribution and acknowledge their last appearance yesterday in their current roles.