Country Health Services

23 Feb 2011 archivespeech

This speech is to move that the Social Development Committee inquire into and report on the current provision and plans for future delivery of Health Services in Regional South Australia.

The Hon. J.M.A. LENSINK (17:22): I move:

That the Social Development Committee inquire into and report on the current provision and plans for future delivery of Health Services in Regional South Australia, with particular reference to—

1. Health Advisory Councils replacing local Hospital Boards, significantly reducing their decision making power and effective contribution to local operations;

2. The consequent decline in local community fundraising due to local communities not having a voice in health spending in their area;

3. How funds previously raised by local communities are now spent;

4. The removal of funding to the Keith, Moonta and Ardrossan Hospitals;

5. Country hospitals failing to receive final 2010-2011 operational budgets so that they are forced to work on indicative budgets and the impact on their ability to make decisions;

6. Property titles of hospitals being transferred inconsistently or inappropriately;

7. The impacts of a state-wide freeze on the hiring of staff for any new positions;

8. Transfer of St. Johns Ambulance to South Australian Ambulance Service and consequent outcomes including:
(a) removal of the ability of local volunteers to decide which community events they attend;
(b) 'fees' for attendance at local community events set by and paid to Country Health SA instead of the traditional system of donations being provided directly to local ambulance stations; and
(c) reduced incentive for new volunteers to participate;

9. The reduction of admission rights for country general practitioners and the consequences for the provision of accident and emergency services across CHSA and community hospitals;

10. The centralisation of purchasing by country hospitals and the consequent impact upon local communities' businesses;

11. Bullying and understaffing at the Port Augusta Hospital;

12. The impact of deeming Country Health as 'local network' for all of regional South Australia within the Federal health system so that different regions within the State have no different identity within the Federal programmes and funding; and

13. All other relevant matters.

In speaking to this motion, I note that there was some discussion in the other place just yesterday. The member for Stuart, who has been a very strong advocate of an inquiry into country health, made a contribution, as did the minister. In relation to these particular terms of reference, he stated:

...if we can come up with a neutral form of words I would be happy to support it, because it is my view that we have a very good story to tell;—
I would dispute that—

...and I think it is important that members of the Liberal Party actually go out there and find out what is really happening rather than what they think is happening, or rather what they have told themselves we are intending to do.

I would just like to put those comments on the record because we are the party representing regional South Australia to the greatest degree. We have a number of regional members and what they tell me is that this is the number one or two issue challenging them in their particular community. So, I think that is a poor reflection by the minister on our members in that they are in touch with their communities, quite frankly, and they hear complaints that fall within these terms of reference on a regular basis. I will refer to a number of those in a moment.

This is a case of 'We told you so' and it is the case that the Liberal Party told the parliament so in relation to the Health Care Bill which was passed in 2008 in which we raised a number of concerns about the way that health, in particular for country areas, was going to evolve under the altered governance arrangements. Local government is no longer a player at the table in Country Health areas and we noted that the new Health Advisory Council structure would mean that there would no longer be any financial control from the local community. We were also concerned that a one size fits all approach would be adopted by the government. A number of those concerns that we raised at the time have come to fruition, and therefore we believe it is timely to have a proper inquiry into all these matters.

In relation to the terms of reference, I will refer to those in turn and in the order in which I have moved them as part of this motion. Firstly, in relation to Health Advisory Councils replacing local hospital boards, significantly reducing their decision-making power and effective contribution to local operations, the decline in local community fundraising and how funds previously raised by local communities are now spent, there is unanimous concern from our regional members, who, I should add, have provided me with information from their local communities in assisting me to make this particular contribution.

Initially, the government had marketed the HAC system with the acronym FACE, which means facilitate discussion, advise and advocate, communicate and consult, and engage with the community and evaluate process, which all sounds very nice on paper, but the reality is that the HACs have become an interface which do not have the power to be able to respond to the concerns of their local communities. I think that, in many ways, this has been a tokenistic approach, in that the HAC can wear the opprobrium of their local community and the department will insist that they sell the government's message, which puts them in a difficult position.

A number of people would have put their hand up to be on those HACs with the best intentions but are unable to respond, which is very frustrating. In effect, the HACs are a way of pretending to local communities that they have a say in running their local hospitals and then they are to be used as a scapegoat if a problem arises, such as saying that the relevant HAC was not consultative enough. We have seen centralisation of administration and that limits the amount of responsiveness to genuine local community concerns.

HACs do not have any responsibility for the running of hospitals, their maintenance, buildings, equipment, or management of staff. As I have said, it is just an interface, and I think that has led to a lack of ownership from local communities because they have become very frustrated with this changed process and, in fact, have given up. In relation to maintenance of hospitals, I think it needs to be acknowledged that lots of our country hospitals are older building stock and therefore need a lot more maintenance than some of the metropolitan hospitals which have undergone significant upgrades over the years. The local hospitals feel like they are not getting the services or funds, and because they are uncertain of their budgets, they tend to underspend in order to make sure that they do not go over, which, in effect, can be a cut by stealth.

We have had advice from the Adelaide Hills and regions such as the Inner North and the Mid North, where either staff or the community have sought that the HAC organise maintenance for them. HACs require the permission of Country Health if they are to expend anything over $5,000. As an example, the Gumeracha hospital has a highly visible rotting front entrance gable. The issues are: firstly, why is Country Health not picking up these issues and resolving them; and, secondly, maintenance, if that is to fall under the HAC, why is the responsibility between the HAC and Country Health SA being blurred? In today's news we see the delaying of repairs to the Karoonda hospital following what I understand to be some storm damage—nothing has been done in that respect.

From the Riverland, people tell us that local HACs have no decision-making powers whatsoever, other than spending money which has been raised by the community itself, up to a figure of $25,000, without further reference to the minister. This is causing immense frustration and anger amongst HAC members who see decisions made about reallocation of staff or reduction in staffing levels, with no reference to the wellbeing of the hospital. Now that the HAC no longer controls finances, cost overruns are usually not divulged to the HAC until well after the problem has occurred. So, when it is too late to take any real action, Country Health SA will let the HAC have that information. This would never have occurred under the previous arrangements while the hospital was under the stewardship of the board.

In the Mallee, maintenance has been an issue with a number of people, as has been their inability to assist in operational matters, and that has led again, as I have said, to people losing interest in being involved, which means that at least two of the HACs do not have a full complement of members. Again, we have reports from there that there are token committees that have little or no input into or influence on how things are done, whereas under the previous board arrangements, they had a strong say on things such as improvements, services and equipment.

Boards had better access to the minister and they had good communication and feedback with the public, but they feel that the information that they gather is not really accepted further up the chain. As a consequence, HAC membership is dwindling. On the Yorke Peninsula, the 10-year rolling strategic plan will provide more focus on monitoring activities against the plan and reporting to the people. This is yet to be implemented and the concern is: who is going to monitor activity against the plan and how will this be achieved?

In the Mid North and the Far North, in the HAC annual report for 2009-10, it is reported that they are still floundering with their roles and are frustrated with their inability to act or to be heard. The report goes on to state, 'One would hope that there may be a shift back to some form of governance and accountability by local persons in the not too distant future.' On page 5 of the Loxton and Districts annual report it states:

Whilst the transition from Boards to HACs occurred in 2008, there continues to be areas of significant concern for the HAC with resultant legislative and administrative issues often creating confusion and challenges and actions undertaken by [Country Health] SA without the prior approval or consultation with the HACs.

The recent intention to change ownership of land titles to CHSA being one example. The Loxton and Districts HAC actively pursued this matter on behalf of our community, and whilst the Minister has directed that land titles be returned to the name of the HAC, we are still awaiting an explanation as to why CHSA intended to change the titles and still waiting for the relevant documentation.

My second point in relation to this motion is that there has been a decline in local community fundraising due to local communities not having a voice in health spending in the area.

I note from the debate yesterday in the House of Assembly that the member for Stuart said that regional communities have probably had a reasonable time this season in terms of not being pressed by droughts and so forth, but they were still not as forthcoming with money as they used to be, and the minister has cited that donations across the board are down. I think that reflects two very different points of view.

On Kangaroo Island, we are advised that the local hospital auxiliary is finding it difficult to raise funds or gain support from the HAC and is being told, 'It isn't our hospital anymore, it's a government hospital, so they can supply the money and buy the equipment.' In the Riverland district there has been a substantial decline in community fundraising since the HAC system has been introduced. Now, however, many of the HACs have wrested back their bank account. In the case of the Loxton Hospital, it has been able to regain control of nearly $1 million of community funds raised which Community Health SA had appropriated during the change from the board to the HAC. Obviously this whole process has been poorly received by the community in Loxton, which is seeing it as a blatant cash grab by the government.

It is a widely held belief that Country Health SA has acted unconscionably in the matter of community funds. As an example, all the Loxton bank accounts were given a new name: Community Health SA Hospital Inc., followed by the name of the HAC. Term deposits were closed and the money placed in low-interest cheque accounts. It is only through their own extreme determination that the HACs have been able to follow the money trail and reclaim the money. Even now, Community Health SA continues to give 'advice' about deductible gift recipient status which is entirely contrary to the advice they have sought and received from the Australian Tax Office. On Yorke Peninsula they have fewer concerns, apparently, with this particular issue; the HAC controls the funds raised and approves where those funds are spent.

Item 3 relates to how funds that have been raised by local communities are now spent. In the Lower North there has been a drop-off in bequeaths, and Kangaroo Island states that it has reasonable funding available but needs ministerial approval to spend over $5,000 at any one time. The local hospital cluster has been told that it cannot spend any more than $25,000 per year as it will 'upset' the AAA credit rating, which I find extraordinary. There has been an issue in relation to large donations to the hospital, and the community now believes that the best place to direct that money is to the hospital auxiliary, as it is now an unincorporated body and does not require permission to expend its funds.

In the Mallee, funds raised locally are held in a separate state account for each HAC, and they can only be spent by that HAC. They do not have as many concerns about fundraising. In the Loxton and Districts annual report, on page 5 it says:

Loxton and Districts HAC is awaiting a 'paper trail' explanation as to how accounts have been closed and a new one established without consultation with the HAC. The Loxton and Districts HAC is seriously concerned, as these events indicate a disregard for the HAC.

Item 4 has had quite a lot of coverage in the media, and we have had demonstrations on the steps of Parliament House. It relates to the removal of funding in the last budget to the Keith, Moonta and Ardrossan hospitals. From what I understand the funding, particularly to Yorke Peninsula hospitals, was a mere $120.05 a day, and that was only when there were persons occupying that bed, so it was really just a payment made for a particular service provided by the hospital.

I think most of us—apart from government members—would agree that it was a disgraceful decision to defund country hospitals and place them at risk, particularly when they provide such a valuable service. Keith is on Highway 1, and provides a valuable A&E service for people who might have a crash on their way to Melbourne. I think it is the view of some of the people in the Keith community that they are hoping that a few Rann government ministers might have a crash there and find out how important that particular service is. Those issues deserve further examination. I think this government is politically against not only country people but also independent hospitals, preferring to fund those that are completely within its control. This is an ideological decision which makes no sense.

Item 5 relates to the operational budgets, and I think most of us would agree that it is invidious to place hospitals in a position where they do not know their operational budget until seven months into the financial year. Again, this will have the impact of being a cut by stealth, because the administrators will be cautious in the way in which they expend their money and will therefore reduce the services available.

In the Mid North, the operating budgets for all hospitals have not yet been received. There is no budget for maintenance and repairs. These are ageing hospitals that require regular maintenance, and the community fears that the lack of repairs will mean that, at some point in the future, the government will declare that the hospitals are no longer safe to use and will be shut down.

The Jamestown hospital has asbestos-backed linoleum flooring; if nothing else, that is a sign that it has not had a new floor for at least 20 or 30 years. The lino has holes in it which have been covered with tape, and requests to have the lino replaced have been unsuccessful. This results in occupational health and safety issues for staff, patients and visitors due to tripping hazards and the potential impact of asbestos to their health.
In the Mallee Health Service, they say it is not unusual for their budgets to be delayed and for staff to continue to manage things on an interim budget. On Yorke Peninsula they say the state budget was late in the first place, which did not help. I now refer to item No. 6, that is, property titles being transferred inconsistently or inappropriately. In the Mid North the hospital titles are to be transferred to the HAC. However, the Orroroo hospital title is crown land and transfer is not automatic or is proving difficult to complete.

In the Riverland we are told that this is another example of Country Health SA trying to boost its asset register by creating vast landholdings in the name of Country Health SA Hospital Inc. In attempting this it is in breach of the Health Care Act 2008. Now that it has been caught out, it has decided to sit on its hands and not transfer crown land titles which it has illegally transferred into the name of the incorporated HACs, despite an assurance by the minister on 27 October 2010. They view this as another desperate effort by the former treasurer to retain the AAA status which is in so much strife thanks to massive borrowing and spending by this government.

The Renmark Paringa hospital land was bequeathed to the community of Renmark, and as a point of law it could be contended that the government has no right to appropriate land that does not belong to it. In the Mallee Health Service, properties have been transferred. Some of those transactions have been very complicated due to different ownership structures. In relation to Mannum, page 5 of the annual report states:
During the past year we have attempted to locate the six land titles for Mannum District Hospital but, after an intense search, were only able to locate three.

I point out that hospitals are very important to their local communities and in days gone by titles used to be located either within the hospital safe or the local bank, which might not seem much to those of us who do not live in country areas, but it is obviously symbolic for the locals that they can access and see those.

In relation to item No. 7—that is, the impacts of a statewide freeze on the hiring of staff for any new positions—many regions report that their staff are working long hours, often in a voluntary capacity, in order to ensure patient safety because of staff shortages. On the Yorke Peninsula the centralisation of administration has meant recruiting procedures are much more long-winded compared to the previous regional system.

I now refer to item No. 8—transfer of the ambulance services and removing the ability of local volunteers to decide which community events they attend. This relates to country shows, whether they be football games, rodeos or other sorts of shows. The volunteers used to provide a donation which would go to the local ambulance service, but now Community Health SA requires that those shows go through a central booking service. I understand that a fee is charged which goes back to Country Health SA and the local ambulance service providers do not have the same flexibility about who attends which particular show, which reduces the incentive for volunteers to participate.

This has caused some upset in particular in the Murray Mallee. Some time can elapse before new volunteers get training and then they are expected to do a certificate II, which is somewhat daunting. They may agree, but in the meantime they lose interest while waiting for training. In the Mid North there have been reports by hospital staff that crews from the SA Ambulance Service have delivered patients from a local hospital to Port Pirie or Port Augusta for a procedure and then left without any further assistance. These patients are then often not retrieved and returned to the hospital from where they came. This is distressing for patients, relatives and staff. Staff are often left arranging patient returns well into the night.

Item No. 9 deals with admission rights. This is an area which has received some considerable media attention, as it should. I note that there was a pre-election commitment that no country A&E would close. In some rural areas there is concern that the reduction in admission rights for country GPs will result in the closure of the A&Es by stealth. On Kangaroo Island, we had major issues in 2009-10 for emergency calls and obstetrics. The deadlock took some time to resolve after the government threatened to put a GP clinic at the health service. In their annual report, the Kangaroo Island HAC says:

The failure of Country Health SA and the local medical practitioners to reach a satisfactory agreement for the provision of services to the KI health service. The community has a clear view that these services should be provided by local GPs with the necessary skill mix. The provision of any of these services by visiting practitioners or a practice set up by Country Health will create an unsustainable local practice and subsequent consequences.

There are also concerns with the Burra hospital, and I report from the local media, as follows:

Until one day in April 2010 things at the Burra hospital were chugging along, with a doctor in attendance to handle emergencies as well as other regular doctor-type things. On that day, with absolutely no prior warning, our doctor's activities were dramatically curtailed and she was forbidden henceforth to associate with emergencies. The hows, whys and wherefores of this have never been explained by Country Health SA other than to state that the doctor was no longer qualified to undertake these duties and that they were not at liberty to divulge anything else.
So, if nothing else, that community deserves an explanation of why that has occurred.

Item No. 10, the centralisation of purchasing by country hospitals and the impact on local businesses, in the Mid North a digital X-ray reader for Jamestown Hospital, at a cost of $70,000, was donated by the Jamestown Ambulance Board. It was decided that the HAC would purchase the unit through Country Health SA so as not to incur GST. SA Health is introducing a statewide radiology service, which is holding up the purchase of the X-ray reader, which is unfortunate at least.

In the Riverland, centralisation from their point of view also means uniformity. It leads to not only impacts on local businesses but also poorer quality and fewer choices for patients and clients. It renders small hospitals unable to use the generosity of local growers, who send vegetables and fruit to the hospital. The Eudunda Kapunda HAC annual report of 2009-10 reports:

The amalgamation of the Eudunda senior citizens' hostel into the Eudunda Kapunda health service is looking possible, but still awaits the final okay. The change of CEO for Country Health SA has stalled the process, but we remain positive that once the new CEO is able to review the situation, the amalgamation will proceed to the benefit of all parties.

I state that because I do not believe that changes in CEOs should stall those processes. Those should be decisions that are made at the local level and should continue post-haste.

Item 11, bullying and understaffing at the Port Augusta hospital, we can extend that to the Pika Wiya Health Service, which I understand is undergoing a report, the findings of which thus far are so serious that they expect there will be an interim report provided soon. There are a number of comments in The Transcontinental that relate to the Port Augusta hospital bullying, most recently on 2 February. I will not read those; people can avail themselves of those if they wish.

Item 12 is the impact of deeming country health as a local network, which I understand was the advice from this state Labor government to the federal government and which the member for Grey, Mr Rowan Ramsey, has labelled ‘not understandable'. In a media release dated 8 February this year, he said:

The Federal Government had promised local management for hospitals and I have been saying for some time, for some unfathomable reason they have accepted the advice of the State Government that the whole of regional South Australia is one local area.
He goes on to say:

It is just not conceivable that a board which has responsibility for hospitals as far apart as Murray Bridge and Coober Pedy, or Mount Gambier and Ceduna can be claimed as any sort of local management.

I can only say that I completely concur with his remarks. The Riverland region has also stated that one local health network for all of country South Australia is outrageous and is totally opposed to the intent of the national health ‘reform'. Clusters of five to six hospitals, with local clinician input and local community involvement and the ability to have their own budgets, would be welcomed by many HACs.

The consequent horse trading that has enabled Country Health SA to claim that it is a local health network for 43 hospitals means that in all likelihood commonwealth funding will be hived off for the four country general hospitals, which are intended to be the larger ones at Mount Gambier, Whyalla and the Riverland, and the small local hospitals will be run down. There will be no local input for small community hospitals. Item 13 is the standard 'All other relevant matters'.

Finally, I turn to the government's own report by its Health Performance Council. 'Reflecting on Results' is the name of the document, and it is dated December 2010. In chapter 3—Community Engagement, under the heading 'How did SA Health Perform?', it states:

It is difficult to foresee how the health outcomes planned for South Australians (including those from at risk populations) can be achieved without effective ongoing engagement with community organisations, in relation to service development, delivery and evaluation.
Further on, it states:

The release of SA Health's Consumer and Community Participation Guideline and Policy in late 2009 marked a positive step towards increasing system wide public participation in health. To date, SA Health's pursuit of community engagement as a core method of achieving all four strategic directions has not been robust or effective.

It continues and is fairly critical of the government's ability to engage or whether it has really been effective. On page 146, it states:

There are examples of individual regions, units and services that have implemented community and stakeholder engagement processes. There is little evidence of SA Health developing an overall strategic approach to its relationships with community organisations and others, for the purpose of achieving its goals and demonstrating its accountability.

With those comments, I commend this motion to the house. There will be more discussions with the government about the terms of reference but, in the meantime, I would encourage all members to examine this issue in some detail, which I think has not travelled. We were all told, 'Everything will be fine; trust the government. It will be responsible.' However, in its implementation of that health care reform bill, the government has failed Country Health residents.

Debate adjourned on motion of Hon. I.K. Hunter.

(Continued 6th April 2011)

The Hon. J.M.A. LENSINK (21:32): Honourable members will be pleased that I will be brief. I did circulate that we (that is, the member for Stuart, myself, the member for Morphett and the minister's office) had come up with an alternative form of words because the minister's office was concerned that the wording in the initial motion may skew the debate, if you like, because the language was not particularly neutral.
We have come up with a set of words which is acceptable and which I think will still cover the intent of what the member for Stuart in particular was seeking to inquire into. I thank honourable members for all of their contributions and look forward to the Social Development Committee reporting on this very important matter in due course.

Amendment carried; motion as amended carried.