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Role and potential of the National Broadband Network

CHAIR —Welcome. Although the committee does not require you to give evidence under oath, I should advise that the hearing is a legal proceeding of the parliament and therefore has the same standing as proceedings of the respective houses. We do not have a written submission from you but we have here quite a bit of information about the organisation from the evidence to date. Would you like to make an opening statement?

Mr Ryan —The Grampians Rural Health Alliance is a not-for-profit joint venture established to represent all the public health services in the region. Our region is the Grampians region, so we stretch from Bacchus Marsh and Melton up to and beyond Horsham and Nhill and across to the South Australian border. So we cover a very large area. Because there is a large number of health services we also have connectivity with community health, acute health, subacute health and aged care. So it is a fairly large group. We have approximately 40 sites. We also have about 160 network connections across that region. So it is a very large expansive wide area network that we provide.

We provide the ICT support services and telecommunications services for that region. Effectively we are a coordinating body. It is all financed through the health services themselves, so effectively it is a bit like volume purchasing. By grouping together we hope to get better deals for telecommunications, shared services and video services, and we do.

Some other aspects of what we do include providing hosted applications from Ballarat. We actually have a shared services centre within Ballarat Health Services, which is the largest tertiary health service in our region. It is a very large referral centre. We have put most of our infrastructure within there, but we also have infrastructure sitting in Melbourne. We have a big connection to Melbourne and that is provided through Telstra.

The majority of our links are Telstra links. Ballarat is covered fairly well by HFC cable—under Neighbourhood Cable—and therefore any sight that is located in Ballarat is currently on Neighbourhood Cable. We offer speeds from two megabits up to 100 megabits and we will soon have some sites on 200 megabits. The 200-megabit services are effectively the backhaul between Melbourne and Ballarat. We also have a disaster recovery site; it is part of Ballarat Health Services, but it is a separate physical site. That will have 200 megabit capability between the two. We are fairly expansive and the services we are providing are largely around video, voice-over-IP telephony and data services.

CHAIR —One of the issues is that we put all the technology in place but the usage of it at the end of the day relies on the people. A lot of the rural health providers are under the pump 24 hours a day and quite often do not get around to engaging with these technological options. Do you do anything in that field, whether it is professional development or taking some of the tasks off them to help them? Could you describe that to us.

Mr Ryan —Because we have the telephone system we have something like 6,000 voice-over-IP handsets out there. The thing with phone handsets is that they are fairly straightforward. It is like most telephone handsets, but there are functions that people can do like forwarding to a mobile phone, providing call queuing and those sorts of things. So we provide some training services in those sorts of things. But when you go up to the next level of usage you are talking about videoconferencing. We have almost 140 video endpoints out there throughout the region and they are heavily utilised. In the last 12 months we have increased from 2,500 hours per annum to 3,500 hours per annum.

CHAIR —Can you give us one example of where it is used.

Mr Ryan —We have got one health service that has multiple campuses. Instead of putting people in cars to attend meetings or to do professional development, and in some cases actually see patients, they now videoconference between all their sites. There could be 100 kilometres between their sites. Instead of that, say, on a Tuesday have a meeting or actually do some physical consultations.

CHAIR —Is that a community health service or a GP service?

Mr Ryan —It is a combination of services. It can be allied health—physios, occupational therapists, speech therapists or wound management. Some remote wound management is happening between the wound management clinics and patients. It is saving on travel. It is a significant reduction on travel and in fact it has almost eliminated travel for some people, which is therefore an accrual of savings back to the health service directly. That also means that the clinician has a much more productive day. There are also the safety issues with jumping in a car and travelling long distances on country roads. That is also a major problem.

Videoconferencing is being used in so many different ways throughout our region. We have not been prescriptive in the way that we use videoconferencing. We are using it very much for anything and everything from professional development to training. We use it a lot for specialist to GP issues. We are starting to move much more towards clinical engagement at these videoconferencing units.

We have mobile trolley based video units that can move around from ward to ward and bed to bed within a hospital. We have got wireless in each of the hospitals that is connected to the wide area network. It is a very technologically advanced environment. Every health service has wireless within the health service. Some are better off than others, so they wire up the entire health service.

CHAIR —Does it depend on the backhaul for the wireless?

Mr Ryan —No, not necessarily. Some of our mobile high-definition videoconferencing units are working on two megabit links. That is shared with voice and data. So on a single link at two megabits it is possible to have a high-quality video conference. But if you want to have two high-quality video conferences two megabits is not enough. So all of a sudden we are starting to jump from a requirement for two, to four, particularly in places like Rainbow, Jeparit and Edenhope. They require a lift from two to four and then we will quickly go from four to 10. I expect the next jump for them after it really takes off will be from 10 to 100.

CHAIR —So we are at the point of having a lot of unusual examples like those you are describing to us and they can run because they have been designed to run on what is available. If you want to upscale those seriously you are talking about upscaling the infrastructure and that is when the NBN rollout becomes significant for all those services.

Mr Ryan —At the moment we are limited in areas like BDSL, which is a variant of ADSL—you can have symmetrical upload and download. But effectively that is going to cap out at about four megabits. We cannot get our 10 megabit links via BDSL. Therefore, it cuts out all of those sites having a dramatic increase in both video and data usage. We need the NBN in order to get to those sites to provide equity of service. Just because you live in Jeparit should not mean that you do not get the same service that you get in Ballarat. To provide equity of health service delivery we need access at those levels.

The next thing for us then is to say, ‘How far are patients travelling?’ We have dealt with the clinicians’ reduction in travel, but it would make sense to reduce how far the patients have to travel. If we could hook up health services directly to homes then patients would not need to travel in for reviews. They might need to travel in for assessments and specialist treatment—physical treatment—but for psychosocial counselling, family counselling, we might hook up a few family members around the country. Instead of them having to fly in at their own expense, stay overnight in a hotel in Melbourne and hover around a specialist and a counsellor, they might be able to do that totally remotely in the privacy of their own homes.

CHAIR —So you are not talking about direct mental health services; you are talking about support to families connected to people managing chronic illness or things like that?

Mr Ryan —Yes. Take dementia as an example. As to dementia services, we have a specialist in Ballarat who travels up to Horsham frequently and conducts, effectively, his reviews. He has basically said that if he could start to conduct those reviews remotely then that would be a big thing for him. Particularly for the family counselling side of dementia management, the key is to have other family members having input—to actually link them into a conference. That is absolutely important. But you need to see the whites of their eyes—you need to see a high-definition image of a patient’s face.

Mr NEVILLE —On that point: what sorts of services are being delivered? I suppose you have described some wound management. Just give me an example there.

Mr Ryan —Our mobile videoconference units have some scopes that sit on the units. They are high-definition scopes—they are what you would normally see through a physical camera.

Mr NEVILLE —Do you do these in the hospitals or bush nursing centres?

Mr Ryan —Correct—it can be done in the bush nursing centres or the hospitals. We actually have a GP who went out and got a government grant to buy one of these and put it in his office—this is in Charlton—but also it is movable out to the Charlton hospital. Unfortunately, the Charlton hospital went under water recently and so did the device, so we were not too happy about that. But the wound nurse was able to look at the wound and project that over to, say, a GP or a specialist so that they could actually have the wound management—particularly reviews—further away from the specialist teaching hospitals.

Mr NEVILLE —And to transmit X-rays—is that possible, too?

Mr Ryan —Transmitting X-rays is a problem at the moment for all of health care.

Mr NEVILLE —Because of speed, or what?

Mr Ryan —It is partly to do with speed, but also it is to do with the compression algorithms and other things that are used. At the moment our video network is not integrated into, say, a data feed. So you can have a videoconference and throw up an image of an X-ray, but that might then mean that your videoconference drops out or that one will be of a lesser quality than the other, if you are limited by bandwidth. So, on a 100-megabit link, you should be able to get video, data, voice and high-quality X-rays projected all at the same time. But you would not be able to do that on a four-megabit link out to Rainbow, for example.

Mr NEVILLE —You described your region, which is a bit more comprehensive than the council’s immediate region. Do they work as separate units, in the sense that the vision appears to be for Ballarat to become the medical hub north of Bacchus Marsh? Yours is the more comprehensive region. Does it have the same sort of central focus on Ballarat, or is it more just a networking organisation for all the hospitals and health professionals in that area?

Mr Ryan —We have effectively three subregions. So we have a Ballarat subregion, a Wimmera subregion and a Grampians subregion. So those three subregions, particularly the Wimmera and Grampians regions, work very closely together. I guess the Ballarat region is really the referral and specialist centre. Because they have the population, they also have the ability to almost volume-purchase by themselves. We actually leverage that ability. So, if you look at the gross operating revenue of, say, Ballarat hospital, it is in the order of $300 million. And if you look at the remainder of the region, it is probably equivalent to $300 million when you take the rest of the region together.

Mr NEVILLE —How many specialists do you have in Ballarat?

Mr Ryan —I do not know. I would have to look up that number.

Mr NEVILLE —This is the specialist centre for the north-west?

Mr Ryan —For a lot of specialties, yes, but of course we have a major referral back towards Melbourne. We use the Royal Children’s, the Austin, the Alfred and the Royal Melbourne for a lot of different specialties. One of our main frustrations is that the Melbourne hospitals have not seen the push to connectivity like we have. We had to reduce costs because of STD calls—we were doing STD calls between Horsham and Ballarat at one point. In order to reduce that they looked at voice over IP, which meant that they looked at telecommunications. Then they had to decide at what point they would start to get additional value, and that turned out to be video, because they did not want to put people in cars. Then it was about trying to make sure that patients are not travelling as far as well. Gaining access to specialists from Melbourne has become increasingly more difficult, and also placing a specialist in Horsham even to do visiting rounds. Fewer and fewer of those specialist rounds are happening—they are getting a pull back towards Melbourne.

So our frustration is that we do not have great connectivity back into the Melbourne hospitals, and we really need it because we can have videoconsults between the Melbourne teaching hospitals and Ballarat and then beyond. Even if we could save the extra hour and a half travel to Melbourne from Ballarat, that is at least something. So we are actually starting to put interconnects in place.

CHAIR —What is the barrier? What is the challenge?

Mr Ryan —The challenge is the model, not so much pure connectivity. Part of it is interoperability between videoconferencing environments. Part of it is to do with the change that is associated with funding models. Specialists in Melbourne are not incentivised to go out to a region; they are incentivised to see the patients physically within their buildings. There needs to be a much more regional focus from the metropolitan hospitals. Some of them have that. Cancer services, for example, is starting to grow throughout Victoria, so we will have the Victorian Cancer Centre sitting in Melbourne and that will then be integrated with each of the cancer centres in regional Victoria. There is very much going to be a regional focus there.

CHAIR —So the dilemma is that the incentive to see the person in rooms means that there is not a driver for the specialists to say, ‘I could see them in my room via videoconference or I could see them in my room physically.’ There is no incentive for them to support the patient who might prefer a videoconference to the 1½ to two hours travel.

Mr Ryan —Correct. There is that pressure, which is partly, hopefully, going to be realised via the Medicare rebates for online consultations. However, then there is the other pressure of state funding models, in that a specialist might need to see a certain number of patients to keep a contract with a particular hospital as well. So there are pressures around demand but there are also pressures around the funding model itself.

CHAIR —Okay.

Mr SYMON —I want to follow the same line of questioning but I will go back a couple. David, you mentioned you have a private broadband network that looks after all your sites. Outside of Ballarat, as I understand it, that is reliant on Telstra’s capabilities in each area.

Mr Ryan —Correct.

Mr SYMON —In any of those areas are you operating from a wireless link at present, or is it always on an ADSL or a similar type of situation outside of Ballarat?

Mr Ryan —We are always on a wired network, apart from the wired network connecting to wireless within the hospitals. But yes, absolutely, it is all wired. We are moving towards full fibre.

Mr SYMON —Even for Rainbow?

Mr Ryan —At a particular bandwidth it is affordable to pull fibre between, say, the Telstra exchange and the hospital, but at those higher bandwidths it is not affordable on a recurrent basis. We might have some capital and put the capital into pulling the fibre, but then it is not affordable on a yearly basis.

Mr SYMON —So you would be waiting with great anticipation for the NBN to come along and put such a link in.

Mr Ryan —Absolutely. If we could get particularly the sites that are on the periphery, almost the last mile, that aspect will make the biggest difference in our region because it will start to see the limitations around video conferencing and other applications being reserved at the same time—x-rays et cetera. Shipping around an MRI takes a massive amount of data and, therefore, it is going to suck up a lot of bandwidth.

Mr SYMON —Do you foresee a time when someone living in a remote area may be able to do this from home rather than having to go to the nearest medium sized town? At present, videoconferencing is not something that many people have in their home, but, with the right linkage, the right speeds available and the way technology moves, I figure it will not be that far off. Is there a space for the medical consultation in that?

Mr Ryan —Absolutely. GPs, specialists, patients, allied health, mental health and all sorts of services should be being accessed from homes. We are actually seeing two aspects. One is about maintenance of the individual inside their home for as long as possible. With an ageing population, we are seeing increasing levels of dementia. One of the things around dementia is that, if we can maintain people in their own environment, the outcome is going to be much better for longer. Ageing in place, of the person’s choosing, is something that we need to address as a nation—therefore, having technology not as a barrier but as a solution. We are looking at things like remote monitoring of the client’s condition. That could be a nurse, a doctor or an allied health professional dialling in and talking to the individual inside their home. They might be able to take blood pressure, blood glucose, and peak flows for asthma and for breathing problems. We are seeing remote monitoring starting to be trialled in some of our sites because they are seeing a lot of pressure around chronic diseases. Particularly with the ageing population, chronic diseases are becoming more and more prevalent. That means that health services are saying, ‘We have to close our doors because we cannot put up with the demand. It is becoming really difficult.’ And the funding models are not keeping pace with it either. They are looking at: ‘Can we remotely monitor a client instead of them coming in and taking up significant clinician time or bouncing around our health system?’ They can be better managed at home.

CHAIR —As a better preventative health intervention in the first place.

Mr Ryan —That is right.

CHAIR —We had evidence from a gentleman who worked on the island project in Tasmania. He said that they had house based monitoring, although he said they had to turn off the cameras. There is a point at which people feel observed in an inappropriate manner in the home. The visual was that point. If it was just monitors and sensors recording people getting out of bed, moving around and things like that made a huge difference in preventive interventions.

Mr Ryan —Correct. Some people classify that as smart homes—being able to put technology inside a home that maintains a person if they are disabled or have particular conditions. There are certain aspects of that that border on privacy issues. That can be dealt with simply by having the consumer choose the types of technology they put in their house. Again, how those sorts of devices are funded and how houses are built needs to be discussed. It will become much more prevalent. Smart homes are becoming more prevalent if you look in the cities. People are putting in special dimmers and electronic devices. In Victoria, we are now seeing smart meters. They might not be doing a lot just yet, but they will have the opportunity to be able to monitor your electricity use and suggest ways of reducing electricity use. All of these things can be wrapped up into an ageing-in-place portfolio.

Mr SYMON —I think you said your network connections stand at 160 at the moment on 40 sites.

Mr Ryan —Correct.

Mr SYMON —That will have several zeros added to the end, under that scenario.

Mr Ryan —That is right and how we manage that and how that works in terms of the health system needs to be addressed as well. Whether that is the consumer taking more ownership for some parts of that or the government taking more ownership of it is a debate the nation needs to have as well. The profile of ageing in this country is going to move us towards having to make these decisions. If we do not make them soon, we could be in for some higher costs than if we were to address it now. The NBN is one of those areas where, if we do this early, it will be sitting there as part of the solution to the problem.

Mr SYMON —You are right. We could not have the debate around health and that connection if we did not have that sort of capacity available.

CHAIR —I just want to wrap up this section and try to get us back on time. Do you have any projects running in the mental health area? One of the things the Rural Health Alliance said to us was that young people are significantly more likely to engage with mental health services online than in person. I am thinking of some of the rural and remote mental health challenges that we face and the capacity for something like this to provide services there.

Mr Ryan —Mental health are effectively our biggest users of video conferencing. Our salaried mental health professionals spend more hours on video conferencing than they do on the road by far.

CHAIR —Could you provide us with some data on that?

Mr Ryan —Absolutely. I can get you a submission on that.

CHAIR —Perhaps even a case study on how it used?

Mr Ryan —Yes, we have got that. In terms of the age brackets, I am not sure if we will have that sort of detail, but we will definitely be able to show you how we are using video conferencing for mental health.

CHAIR —That would be fantastic. Thank you for your attendance here today. You have given us some very useful information. The additional information you have undertaken to provide can just go through to the secretary’s email address. We will send a copy of the transcript of your evidence to you, to which you can make corrections of grammar and fact. Once again, thank you very much for your useful evidence today.

[12.12 pm]