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Senate Select Committee on Health

BONNER, Mr Rob, Director, Operations and Strategy, Australian Nursing and Midwifery Federation (SA Branch)

DABARS, Adjunct Associate Professor Elizabeth, AM, CEO and Secretary, Australian Nursing and Midwifery Federation (SA Branch)

HURLEY, Ms Jennifer Margaret, Manager, Professional Programs, Australian Nursing and Midwifery Federation (SA Branch)


CHAIR: Welcome. I understand, Professor Dabars, that you have to leave us shortly, so we will seek your permission and also permission from the committee to be filmed by the television here. We are all in agreement. Thank you for joining us this morning and giving us your expertise. I am assuming that someone is going to make an opening statement.

Prof. Dabars : Yes. I will be making an opening statement and, as you indicated earlier, unfortunately at a certain juncture I will have to leave. Fortunately my colleagues here are absolutely expert in the area and I think that you will be very ably assisted by them. I will try and stay for some questions as well; but, to be perfectly frank, I am surrounded by experts so I may be calling on their assistance in any event. In making the opening comments from the Australian Nursing and Midwifery Federation SA Branch, I do want to note and adopt the submission of the ANMF federally, which was made to the committee in September this year. We also rely on their submissions that were made to the Senate Standing Committee on Community Affairs in relation to out-of-pocket costs in the Australian healthcare system in May of this year.

We are deeply concerned by the impact of this year's federal budget, which effectively tore up the National Health Reform Agreement and terminated a number of partnership agreements that were directed towards specific health system improvements for particular groups of people with chronic healthcare conditions. Our concerns, from the perspective of the ANMF SA Branch, can be summarised as follows. Firstly, the federal budget will slash billions of dollars from state hospitals in the coming years. This is money that was specifically provided for by agreements entered into by the Commonwealth and state governments. Of course, while it is true that this year's state budget showed that the Commonwealth contribution to the state health system grew, it is equally indisputable that over the forward estimates some $650 million worth of Commonwealth funds previously committed will no longer be received by South Australia. We are advised by the South Australian Treasury that this figure does grow steadily until it reaches in excess of $920 million per annum by the year 2024-25. The effect of reductions of that magnitude basically equates to the funding that was previously assured by the Commonwealth, effectively equates to the loss of funding for an entire health region—that being the Southern Adelaide LHN in this year's budget, which of course, as I am sure you are familiar, really equates to the Flinders Medical Centre, the Noarlunga Health Service and the Repatriation General Hospital. That would be absolutely devastating for the South Australian community.

The second point is that the introduction of co-payments for a range of health services—GP visits, pathology tests, radiology services—and the increases in pharmaceutical payments will, in our submission, likely lead to those people most in need of attending those services either avoiding them or delaying seeking care due to costs. In addition to the personal and unintended social and economic impacts that co-payments will have, they will add to the cost of our healthcare system over time. People avoiding visiting the GP and whose health conditions worsen will ultimately attend the hospital emergency department acutely unwell. People taking multiple medications for chronic health conditions and who become partially or wholly noncompliant with those directions again will become more unwell and require additional services. Those costs will impact the most vulnerable in our community: those on benefits or pensions, the lower paid and especially those with families, but also, research suggests, disproportionately on Indigenous people, on women, on the elderly and on those with chronic diseases such as asthma or mental health conditions.

I noticed you were talking earlier about studies that are available. There was a study undertaken by the Commonwealth Fund, reported in June 2014, that in below average income households 14 per cent of people had not seen a doctor for a medical problem in the previous year, and in above average households the result was five per cent. Fourteen per cent of below average income households had avoided or skipped medications, while the figure for above average income people was eight per cent.

The third point I would like to make is that the Commonwealth is essentially walking away from its role in primary and preventative health care. Under the reform agreement, the Commonwealth was to assume a greater role for the funding of primary health services. That is a wider role than the historic federal role in the funding of primary medical services. It took the Commonwealth into a greater responsibility for funding of community based health care, particularly into the areas of multidisciplinary healthcare delivery for disease prevention and for health promotion.

The budget cuts to health promotion and disease prevention programs are both short-sighted and counterintuitive in our estimation. If the aim of the budget is to reduce the future costs of the health system, how then could a responsible budget cut the very programs that are designed to address factors that will lead to an increase in demand for health services in the future?

Finally, we also question the basic need for those budget cuts in the first place. The Treasurer and the Minister for Health at the federal level have warned of the unsustainable growth in health spending in Australia, along with suggestions that co-payments are necessary to send a price signal to those people unnecessarily visiting GPs. But what is the evidence saying about those claims?

A new report by the Australian Institute of Health and Welfare, which is of course a Commonwealth government body, in September this year reveals that the government's claims were wrong and in fact misleading. Its report Health expenditure Australia 2012-13 gives the latest comprehensive picture about the costs of the health system and who pays for it. Real growth in health spending across all sectors was only 1.5 per cent in the year 2012-13. The average real growth in health costs for the decade 2002-03 through to 2012-13 was 5.1 per cent per annum. So the most recent growth has been at the lower end of the growth spectrum rather than indicating spiralling or continuing high levels of growth that could be expected from a system if it were actually out of control. For the same decade—so that is 2002-03 through to 2012-13—health expenditure as a share of GDP was an average of 9.01 per cent, and in 2012-13 it was 9.67 per cent. When population changes are taken into account, the picture is even more at odds with the budget doom and gloom. The total expenditure per person actually fell in real terms in 2012-13 by 0.3 per cent, and had grown by only 3.4 per cent for the decade 2002-03 through to 2012-13.

The cost of health expenditure as a share of all tax revenue is now declining following recovery of tax revenue after the GFC. Again, that reality is at odds with an unaffordable or unsustainable system. The recovery in tax revenue is most marked in the Commonwealth's income, while the states' and territories' growth is far more moderate.

Just as importantly the need for a new price signal in the form of a co-payment, to control the demand for health services, is also questionable, given that the volume of services in 2012-13 actually declined by 1.11 per cent. The federal government's share of responsibility for funding health fell by 2.2 per cent during the decade 2002-03 through to 2012-13, with state governments, health insurers and individuals all increasing their contributions. That means that the federal budget strategy of slugging individuals for co-payments on GP visits, pathology and radiology tests and for prescriptions will further add to the costs already felt by families over the last decade.

I would like to thank you for the opportunity to attend. I will have to depart shortly, but I did want to come here and present before you. I am happy to answer your questions, and my colleagues also are experts in the field.

CHAIR: We have had critiqued in the public place the concept that there was a great big budget emergency, but Australians simply do not believe that any more. After a bit of time the reality is wearing thin. They are figuring out that that was a confected crisis. You have effectively just said to us that the health crisis that has been confected by the federal government is the same sort of misrepresentation of reality. So, in truth, there is no crisis in the health system. Is that correct?

Prof. Dabars : That is correct. There is no crisis in the health system, as it has been described by them. Certainly the health crisis that has been experienced by our system is one that would be created in the event that they actually withdraw this funding and impose the additional burden on consumers or the public that they are proposing to do by virtue of their confected crisis. We actually think that the crisis will in fact be created by them. It is not a reaction that they are responding to. They are actually creating a crisis for our community.

CHAIR: So the health system was in reasonable shape when the Abbott government took up the reigns, but they are about to inflict a crisis on the nation. Is that correct?

Prof. Dabars : We are very concerned that the consequences they will be imposing will lead people to avoid or not be able to uptake appropriate health assistance in a timely and effective manner, in terms of accessing GP services. Also the simplistic withdrawal of funding from the system will add such a burden on the South Australian health care system. Effectively stripping out so much money as to remove in its entirety an entire local health network will create a health crisis in our community.

CHAIR: We have had the words 'crazy' and 'chaos' used in the last couple of days.

Senator CAMERON: That was quite a comprehensive opening statement. I notice you are reading from a prepared statement. Is that available for tabling?

Prof. Dabars : We certainly can make a copy available to you.

Senator CAMERON: I would like to move that that document be tabled.

CHAIR: There being no objection, it is so ordered.

Senator CAMERON: We have had lots of submissions on the macroeconomic position this budget delivers for the health system generally, but could you give us an overview as to the implications for midwives and nurses and then the implications for the health of the public as a result of this budget?

Prof. Dabars : From our perspective, the Nursing and Midwifery Federation wants to make a positive contribution to the health of the community, and the method by which it is proposing to do that is by improving quality of care by undertaking various works that we are involved in—for instance, implementing evidence based practice in the system. We think that there are methods by which the Nursing and Midwifery Federation could make an enormous contribution to improve the health and welfare of our system. As I said, by implementing evidence based practice, we are already involved in a program at a state level which looks at how, if we were to be able to implement evidence based practice, we could make some cost savings to the system which we think would help the system overall but could in fact be reinvested into the healthcare system in a positive and productive way. Taking the approach that they have, I think, puts at risk some of those strategies and some of those programs that could benefit the community at large, and we are extremely concerned that the consequences of just imposing cuts will result in nurses and midwives being forced into a position where they are going to compromise quality of care, so they are simply asked to do more with less. I think that is an extremely dangerous situation and one that would place our nurses and midwives at professional risk because, at the end of the day, if an employer or the state government—or the federal government, for that matter—imposes obligations on them which mean that they simply do not have the resources, the support or the ability to provide appropriate care for their patients then it is they who will end up in front of the registration board having their professional livelihoods stripped and their credentials attacked because they were not able to maintain an appropriate standard of care. So the workloads will increase and their ability to provide appropriate and safe care will be compromised.

The other issue, of course, is that the alternative to that is that services are simply stripped back, so there is a reduction in services. A reduction in services, of course, simply means that the community gets less ability to access those services. We already know that in South Australia we have unmet needs. We have people who need the services of our health professionals but are not necessarily receiving that assistance as quickly as they really deserve or need. Our concern is that that would only become far worse in the case of that money being stripped by the system.

Mr Bonner : One of the effects of increasing workloads and decreasing the number of nurses and midwives available, judging from all the international research, is that we have poorer outcomes for clients. So people who go into our public hospitals and health services will stay for longer and they will acquire hospital based infections or other hospital acquired illnesses that will adversely impact on their health as a whole. Without being dramatic about it, there is a direct association between nurse staffing levels and the morbidity and mortality of clients, so if this budget impacts on that then it will directly impact on health. You heard this morning from the LHNs about some of the changes in primary health land, and clearly one of the agendas, moving back into the primary healthcare reform parts of this package, is trying to put an increased focus back on GPs at the expense of the multidisciplinary approach to primary health care, which is clearly important to the bettering of services to clients as a whole.

From our profession's point of view, the other two big impacts it will have are, first, that if there are to be significant job cuts then the people who will feel it first are the new graduates coming out of our university programs, who will not be able to get jobs, and, second, that we know that by 2025 there are forecast to be very significant shortages of nurses to meet the community's needs. So, if we start losing those new graduates as the first reaction, we will actually be cutting the system's throat in terms of future workforce over the next decade. So we would argue that those are unintended consequences too.

Senator CAMERON: It seems to me that the evidence that we have been receiving is that the government's position seems to be a triumph of economic ideology over common sense. I am just wondering whether you managed to have any discussions, because you have put forward a powerful argument in your submission today, with the government prior to that budget, or whether you have had any discussions or consultation with the government after the budget, or whether any of the coalition's South Australian MPs and senators have raised similar concerns or agreed with your concerns?

Prof. Dabars : We have done a number of things, as you would expect. I do not believe anyone was really aware prior to the budget announcements that this was the approach that people were taking, and so my understanding is that certainly not from our perspective did we have any conversations with anyone about this. Since the budget was announced, however, we have done a number of things. We have in fact formed an alliance of interested stakeholder members and created a creature called the SA health alliance, which is absolutely opposed to the federal budget cuts, and I am the convener of that alliance. Some of the people who are members of that include the Health Consumers' Alliance, for instance, who you will meet with later today. As that group, we have actually met with a number of senators. We have met with the ALP and with the Greens. We have met with Ricky Muir. We sought a meeting with Minister Dutton, and he did agree to meet but, unfortunately, on the day, he was unavailable, so we met with his senior adviser, which we were very disappointed with but we still put the case forward. What we were receiving was, as you would expect, some mixed views. The ALP and the Greens have indicated that they are deeply concerned with the issues we have raised. Senator Xenophon—sorry; I should mention him as well—has also indicated grave concern, given the issues that we were identifying. As to Ricky Muir, we were very pleased with the responsiveness that he indicated to us. We were quite disappointed with our meeting—notwithstanding that it was not actually directly with the health minister—with the minister's adviser, who indicated that they were proceeding in the direction that they had publicly announced, irrespective. The only move that we saw that was positive and productive was that we also raised a related issue about some unintended consequences that changes to the Aged Care Act had had in increasing the numbers of aged-care people within our hospital system who could not exit to a nursing home or appropriate facility for an extended period. It had actually increased those numbers from about 40 in our hospital beds to about 120, virtually overnight, as a result of changes to that act, and there was a commitment made to addressing that unintended consequence. But, apart from that—and I am aware that my counterpart federally, Lee Thomas, has in fact met with Minister Dutton, and my understanding—and of course it is third-hand—was that he indicated that they would agree to disagree, and that is as far as it went really, which was, again, disappointing.

We think that these issues are real. We think these issues are live ones. As my colleague Mr Bonner said, one of the most serious issues is about the consequence to our patients and our community. We do not want to see a situation where people's health care is compromised. And we really think that the consequences of this action would be one of two things. It would either be reducing quality, which, again, has a negative direct impact on people's care and their morbidity and mortality, but also access and availability to services is the only other—

Senator CAMERON: So you basically see that people could die because of these cuts?

Prof. Dabars : That is absolutely a potential result, because, if the quality diminishes or the accessibility is not there, either one of those circumstances could lead to a situation where people cannot access the health care that they need. Certainly, mortality, morbidity, or—the simple way to say that—death, is a real concern.

Senator CAMERON: In relation to your local coalition senators and MPs, I have found them really weak-kneed and jelly-backed when it comes to any capacity to look after the South Australian public, whether it is on jobs, whether it is on health, whether is on education. Have you managed to actually engage any of these weak-kneed, jelly-backed South Australian coalition politicians and get them to understand any of these issues?

Prof. Dabars : I would never use such language about our politicians, but given that you have—

Senator CAMERON: It is the truth.

Prof. Dabars : Given that you have, I will adopt your language! At the end of the day, we hear our people indicating that they do have concerns about these issues, but whether the actions follow suit is the question. I know that at a very local level we have had some dialogue with both the Premier and the opposition leader, Steven Marshall, and with the health minister. Of course, as you would be well aware because he has already presented to your inquiry, the Premier has his own campaign running to oppose these cuts. We have been involved as a group that he invites occasionally to hear about—

Senator CAMERON: You would expect the Premier to be taking the position he is taking to try and look after the health system in South Australia. But you would also expect coalition MPs who have South Australian constituents—some of whom, from your evidence, may die because these cuts—to stand up for them. That is the issue for me.

Prof. Dabars : I think the most disappointing response that we have had so far, to be perfectly frank with you, is the response we received from Bob Day, which was that he was unable to meet with us. When we continued to press and continued to press, we got a response saying that, unfortunately, the area on which we wanted to meet with him does not, he says, fits within his portfolio or the priorities that were part of his election platform which relate to families, housing and education. Quite frankly, our question is: what is the point of housing and education or even having a family if you do not have your health? How are you supposed to look after your family if you cannot access appropriate health care? So we were very surprised by this rigid and extremely single-minded approach to our concerns and the fact that we still have not been able to meet with him.

Senator CAMERON: I just want to clarify this. You are saying that you have had some discussions with coalition senators and MPs who say one thing to you privately but that is not reflected publicly?

Prof. Dabars : No, not necessarily. I think that some of the coalition MPs have been receptive to our concerns. What they ultimately do with that, I do not know. We have met with Senator Fawcett. We have also met with Senator Ruston, and she gave a very clear indication that she did adhere to the principles of universal health care, that she subscribed to the principles of primary and preventative health care, but she did not deviate from coalition policy. That is the response we got there. And Senator Fawcett did ask for more information. So we have an open dialogue with him and we have committed to providing more information to him.

CHAIR: Senator Wright.

Senator WRIGHT: Thank you very much for taking the time to attend today. I am really concerned about the evidence you have given about the effect on your own members. Clearly you have a larger concern for the health of the public—and one would expect that from an organisation like yours. But let us go back to the pressures on your members. We know that there are already serious strains in the South Australian health system. We are hearing about people not being able to get the services they need, even if they are in acute circumstances with mental illness—or about aged people being held in emergency departments. I can only imagine the pressure on your members. You have actually said, and others are saying, that there will likely be deaths because of these cuts. When there are deaths, there are coroner's reports, there are inquiries. My experience in life is that someone always ends up shouldering the blame—and it is not usually at the high level; it is usually at the lower level. Can I just hear a little bit more about what concerns there might be, then, in terms of the stress on your own members—as well as their ability to carry out their jobs in the professional way they would want to.

Prof. Dabars : You are quite right. The nurses and midwives across South Australia are already working extremely hard. They have been through—or, in some cases, are still experiencing—significant stress and pressure on the system. It is quite unrelenting at the moment and our concern is that that pressure simply is not sustainable. If the pressure is already at an unsustainable level, the removal of funding is obviously just going to make that even worse. I think it comes down to those principles of the nursing and midwifery profession. People get into the profession because they genuinely want to care for other people. They genuinely want to make a difference in people's lives. The evidence is that, if they cannot feel like they are able to meet their obligations—and they do have professional obligations to their patients as well as their own personal objectives—they ultimately depart the system.

We are in a situation—I think Mr Bonner mentioned this—where we have a serious workforce shortfall facing us. We are expecting at least 4,000 nurses and midwifes to depart the system over the next five to 10 years as a result of retirements. We already have an issue with graduate nurse and midwife uptake now—let alone what the future consequences will be if there is further money stripped from the system. We see a very difficult set of circumstances where, at the same time as those senior people are saying, 'I cannot tolerate this anymore; perhaps I would have stayed on a few years extra, but now I cannot possibly stand the situation because it is both professionally and personally demoralising', there are new people potentially entering the system unsupported and unaided—novices expected to take up the work of senior skilled expert clinicians. I do not think that is going to be terribly productive for their longevity in the system either. The pressure is something we need to acknowledge now, but we need to ameliorate it rather than placing additional pressures and burdens on people.

Mr Bonner : There is no doubt that these budget cuts will impact on workloads across the system as a whole—whether we are talking about extra people turning up at the emergency department because they cannot access their GP due to cost or other issues, or whether we are talking about mental health clients not getting care in the community to keep them well and living normally and having to seek care once their condition has escalated. Those things will add to people coming to hospitals for more care—and we will have a reduced capacity to provide it. At the same time, we are having difficulty getting people back out the other end after they have had their acute hospital stay, back into living in the community with appropriate support or into residential care if that is where they need to be—if you are talking about an older person following an acute care episode. All of this is just leading to a picture of increasing gridlock within our acute hospital system, which is of course where the high costs are.

Senator WRIGHT: It is almost like a perfect storm in a way, isn't it? It seems, from all the evidence we have been hearing, that you are going to have more and more people being funnelled into hospitals. It is going to be harder for people to get out. They are going to be sicker when they arrive. There will perhaps be fewer staff to manage them. Some hospitals will even potentially close, so there will be fewer beds. Then we are going to be dealing with the consequences of that.

Can I take you to the GP co-payment and the proposed increase in the cost of having a prescription filled?

I am really interested in the statistics that you referred to, Professor Dabars. We are being told that that change is important to have as a price signal to stop unnecessary GP visits and unnecessary medication costs, and yet the evidence that you have given is that, at almost twice the rate, people on below-average incomes have not seen a doctor for a medical problem in the previous year. And yet we would expect the alternative to that, given that we know that people on lower incomes generally have poorer health outcomes and perhaps need to see doctors more often. You would perhaps expect that people on below-average incomes might need to have more medical attention, but they are actually seeing doctors at half the rate at which people in above-average-income households see them. Also there is the statistic that almost 14 per cent to eight per cent of below-average-income households have avoided or skipped medications. It is ironic, isn't it, that we are being told that there needs to be a price signal to stop unnecessary visits, but what you are saying, I think, is that that will disproportionately affect the people who are already not seeing doctors and not filling scripts because they do not have the income to do it.

Prof. Dabars : That is absolutely our concern. Ultimately, really, we think that this method will act as a genuine disincentive for people to access that health care in an appropriate and timely manner, and the consequence of that is that they will become more unwell, and ultimately they will just need to appear at the emergency department. We think that is absolutely counterproductive. The ideal in terms of both a benefit for the individual and a benefit for the community in taxpayer dollars would be, as much as practicable, to keep people as well as possible as early as possible and keep them out of hospital. It just does not add up, we think, from a real sense. But I will refer to Mr Bonner on some of those particular figures as well.

Mr Bonner : The Commonwealth Fund study showed that Australia was the third worst of the 11 countries in the study. It ranked only really behind the US and the Netherlands in relation to prescription costs impacting on low-income people. So this idea that we need to put more costs into the system to disincentivise people from unnecessarily taking drugs or turning up at GP services is just clearly a nonsense because we are already up there amongst the most highly hit for co-payments, whether you are talking about scripts, GPs or other tests.

Senator WRIGHT: Given that you would assume that a script has been prescribed because the medication is necessary, wouldn't it be logical to think that in fact we might be wanting to encourage people to see a doctor when they need to and to have a script filled because it has been prescribed?

Mr Bonner : Yes.

Prof. Dabars : You would imagine that that would be the case, but surprisingly it does not seem to be quite—

Mr Bonner : It is frightening when you think that one in six people of below-average income is skipping, already, some or all of their prescription medications. If you are getting that level of noncompliance now, what would that look like if you increased by another $7 the level of the price of each of those scripts?

Senator WRIGHT: I have just one more question. I am just interested in the barriers to access to medical services, to health services. What are the current barriers to accessing hospitals and emergency departments, and then what will the barriers be? Will there be increased barriers—and you have indicated that there will be—if these cuts and changes go ahead?

Prof. Dabars : If you are talking about the broad entry points, one of the obvious barriers is the availability in a timely way of the local GP in the first instance. That is an obvious pre-existing barrier. We in fact have suggested some productive solutions to those types of barriers in terms of accessibility and availability by suggesting that there may be some appropriate and viable role for nurse practitioners and advanced practice nurses in primary health care. That would improve accessibility, quality and availability of those types of services.

In terms of the other emergency-type services, I think the issue remains that our hospital system has become, as we said before, very pressured at the moment. It depends on the nature of your condition. If you have a really severe condition such as an obvious trauma because you have been in a car accident, you are not going to have a problem getting into the emergency department and being seen in a timely, appropriate manner. However, if you have a mental health condition that is slowly degenerating, your prospects are probably a little bit more at risk because you are not as obviously in a state of concern.

So the issue is really those missed opportunities to prevent people's illnesses from going into decline and also those opportunities—for instance, I know that a lot of work has been put in with elective surgery and the like to improve those statistics. At the moment, they have done a lot of work. They have added a lot of resources into the system to improve their elective surgery lists and to get people seen appropriately, but, again, if these cuts come into play, we would be deeply concerned about people's ability to be seen in a timely, appropriate way.

Mr Bonner : The other thing that I think is at the heart of the tearing up of the National Health Reform Agreement is the fact that that agreement was crucial to trying to create a picture of a single, integrated health system for the country, with the Commonwealth and the states and the non-government sector all playing their part in the delivery, but it was joined up. The effect of this budget is to take us back to the Commonwealth saying, 'The hospitals are your problem, sovereign government states'—whatever that happens to mean—opting out of some of the primary and preventive healthcare stuff that they were supposed to pick up responsibility for under the reform agreement and retreating to private GPs and prescriptions again. So we have lost in this budget the goal of creating a unified system that tries to integrate aged care, integrates primary care, deals with mental health services and brings them together in a sensible, collaborative, cost-effective way. I think that that is the real loss of the reform agreement—as well as all the other consequences we have talked about.

Senator McLUCAS: I think you have just encapsulated exactly what the former government was trying to achieve. The sort of cultural change you are talking about is massive and was never going to happen in one budget. But, frankly, this budget has pulled apart six years of really hard work to try and achieve a joined-up system that had the patient at the centre—but I do go on! I know we are late.

I just want clarification of one statistic. You pointed, Professor, to 14 per cent of low-income earners having deferred or delayed attendance at a GP compared with five per cent, I think the figure was, of high-income earners. Can I extrapolate from that that nine per cent of people deferred or delayed probably because of cost? Five per cent is probably the number of people who do not go because they are too busy or cannot get there or something like that, but, if those are equal, then nine per cent, you can say, did not go because of cost?

Mr Bonner : I am not sure that you can, because of course both sets of those figures meet at the point of the average-income family, so the high end of the low incomes or below-average incomes and the bottom end of the high income might only be a dollar or two apart. I think the likelihood is more that the bottom end of the above average are also missing out, and the top end of the above average are doing very nicely, thank you very much, and are going to skip through these reforms without any particular worry. But middle class and poorer people are going to be the people who are slugged and miss out in terms of the health outcomes.

Senator McLUCAS: Absolutely. I would like another clarification as well. A lot of the commentary around attendance at accident and emergency or emergency departments seems to presuppose that, okay, I wake up; I feel sick, and I do not have any money to go to my regular GP so I will just attend the accident and emergency department. I think that is a bit simplistic as a commentary. It has been put to us that it is actually the delayed attendance at a GP, probably, because it should have been a GP type attendance, which then ends up with people ending up at accident and emergency with complex conditions that should have been treated some time ago as a regular GP attendance.

Prof. Dabars : That is certainly our understanding of the situation. We have close relationships with our emergency department nurses and the sense that we have is that it is not very common that people are rocking up just because, as you say, they woke up that morning with a bit of a cold and decided they would trot down to see their local friendly emergency department as opposed to their GP. I think most people realise these days that it is not an appropriate place to go. To be perfectly frank with you, my understanding is that in those infrequent cases where there is an attendance that is entirely inappropriate there is probably a concurrent mental health issue associated with the attendance and really it is more of a friendship visit. That is an entirely different issue that is not going to be addressed by this alleged solution.

CHAIR: I loved your language there about the friendship visit—spoken like a health professional. I have a couple of questions on notice I would like to have asked you about the dissolution, the abolition if you will, of Health Workforce Australia and its impact on the nursing sector when you are clearly already under some pressure in that area, and also about of the abolition of the National Preventive Health Agency. Do you have any brief remarks and then will you take a fuller time to respond in writing?

Mr Bonner : Concerning the abolition of the Australian National Preventive Health Agency, the whole attack in this budget on primary and preventive strategies is one of the worst aspects of the direction it has set out because it just means that we are, as a nation, disinvesting in the only thing that will stop people getting sick and turning up for acute hospital care in the future, as well as depriving the people who are affected by chronic illness with lower levels of social engagement and lower levels of joy in their lives than would otherwise have been the case. That is our broad position in relation to preventive health.

In terms of Health Workforce Australia, Health Workforce Australia was not necessarily a fabulous success, to be perfectly honest, from our perspective, but the loss of an agency charged with responsibility for building a future health workforce capacity I think is a significant one for the nation. The loss of Health Workforce Australia was not necessarily an issue but the loss of a focus on health workforce policy and really just taking our hands off the wheel in that area, linked with their education reforms and the impact of those on future health workforce should be a very serious concern to us all.

CHAIR: We will look forward to some more remarks in due course. Thank you.

Pr oceedings suspended from 12:18 to 13:01