Social Development Committee:Rural Health

Extract from Hansard

Legislative Council
8 November 2000

Sandra Kanck
Deputy Leader Australian Democrats
Member of the Legislative Council

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The Hon. SANDRA KANCK: It is now more than four years since I moved a motion in this place to refer to the Social Development Committee a reference regarding my concern about country obstetric services.

The Hon. SANDRA KANCK: They do move very quickly-blink your eyes and things pass! At the time I considered this to be an extremely important motion, because of the turmoil that was existent in South Australia over country obstetrics, particularly in the South-East of the state. In that region women were being denied access to obstetric services because of what amounted to industrial action being taken by GPs because of the high cost of medical indemnity insurance.

It certainly angered me to see pregnant women being used as bargaining tools by these doctors. However, the action did work for them and the state government intervened and took action to subsidise the medical indemnity insurance of South Australian rural GPs.

In the meantime, other references came before the committee and, because the heat appeared to have gone out of the country obstetrics issue, as the mover of the original motion I agreed to allow another reference to be given priority on the proviso that when we came to consider this reference we would widen the terms of reference to investigate a variety of rural health issues, and the committee agreed to this.

As it was the issue of medical indemnity insurance that acted as the catalyst for me to move the original reference to the Social Development Committee, this is the first issue I wish to address in looking at the results of the committee's inquiry. It was then and remains my view that subsidising the business on-costs of any professional group is not an appropriate role for government and the problem ought to be addressed at its source; that is, the acquisitive and sometimes irresponsible attitude of some lawyers seeking to make money for a client regardless of the consequences, taking advantage of judges-

The Hon. SANDRA KANCK: Regardless of the consequences that have occurred; for instance, the shutting down of a hospital when a lawyer decides to take a doctor for-

The Hon. SANDRA KANCK: Well, that is what I am saying: there are judges who do not understand the issues when they are brought to their attention. In fact, one-

The Hon. SANDRA KANCK: No, it is not about adequate insurance; it is about smart alec lawyers.

The Hon. SANDRA KANCK: -in Adelaide as a consequence of actions by lawyers on medical indemnity insurance.

The Hon. SANDRA KANCK: No, it is not a consequence of medical negligence. In fact, Doctor Richard Watts of Port Lincoln in his evidence to the committee said:

I also believe that the judges who adjudicate on these cases for example, cerebral palsy from birth difficulties, these judges need to be educated on the role of birth trauma in the generation of these illnesses.

So there are lawyers who are willing to prey on the lack of knowledge that judges have about certain medical procedures and the consequences of those procedures. Terms of reference (iv) `the impact of medical indemnity insurance' and (v) `the role played by government in the negotiating and brokering of medical indemnity insurance' invoked responses of support for the state government subsidy to GPs for their medical indemnity insurance. The widely held view was that this was a positive and should be continued, and the committee has recommended that way. Nevertheless I note that, in its submission to the committee, the Barossa Area Health Services observed that doctors saved quite a deal of money from the subsidy from the state government but, as a consequence of that subsidy, no private obstetric patients were being admitted to the Tanunda Hospital so, in a sense, the doctors pocketed the difference. The Barossa Area Health Services stated that the board has concerns that it was not involved at any stage with the negotiation and brokerage of the medical indemnity insurance issues. As the legal entity, the board considers that it should have been a partner in the negotiations.

Because they were generally happy with the way things now stand, a number of submissions and references to the committee's initial questionnaire glossed over our terms of reference, which stated:

vi. improvement in the claims management and work practices by the medical profession with a view to reducing the number of claims and therefore reducing the cost of medical indemnity insurance.

vii. the role of the legal system and its effect on the cost of medical indemnity insurance.

Those who chose to comment were unanimous in the view that smart alec lawyers play a principal role in hoisting up the premiums for medical indemnity insurance. I draw the Hon. Mr Xenophon's attention to the fact that this was an almost universal view from the hospitals and health services in rural South Australia that commented. If the Hon. Mr Xenophon takes exception to it-

The Hon. SANDRA KANCK: -he had better make contact with the hospitals and health services in the rural regions of South Australia and tell them that they are wrong. Dr Graham Fleming of Tumby Bay made a reasonably detailed submission on this issue. It is worthwhile hearing what he had to say, as follows:

Unfortunately, the legal system is one of the main reasons that medical indemnity insurance has increased in recent years. One of the main problems is that medical indemnity insurance is mostly dependent on case. . . law and is open to much interpretation and precedence. It is obviously very messy but case law can only be superseded by legislation. No Attorney-General is going to introduce legislation to simplify the law because the legal profession, of which they are usually a member, would so violently oppose any changes, it would make the Attorney-General's life intolerable. Medical indemnity cases are fertile ground for the legal profession and it is not surprising it is getting easier for the lawyers. Most rural hospitals and no rural general practitioner can match the standards demanded by case law. For example-

duty of care. . . .Rural general practitioners have a duty of care to provide to anyone who calls for emergency assistance. There is no way of ascertaining whether it is a true emergency unless that general practitioner sees the patients and documents the facts. Once the patient has been seen there is a duty of care for treatment or for referral.

Unfortunately, if there is no-one else to refer to, the rural doctor then becomes responsible for the treatment. In other words, rural general practitioners have an unrestrained legal duty of care to all members of the public within their geographic area which is physically and legally impossible to meet. Rural hospitals with an outreach service have a similar duty of care but, if a patient calls the hospital after hours, there is no facility to provide acute care. The duty of care demanded by case law is `a reasonable general practitioner or health facility with reasonable resources'. The fact that inadequate resources have been provided or do not exist is not a legal exemption. In fact, most rural general practitioners and rural health facilities fail this standard of duty of care from time to time.

For example, a general practitioner who has been up all night with an emergency and is confronted with a patient with a severe myocardial infarction has a duty to provide emergency care even though he or she may not be mentally capable of doing it well. Unfortunately, this is not an acceptable defence. It is wrong to believe the courts will take this into consideration, as they have ignored it by precedent in the past.

The Hon. SANDRA KANCK: A patient being treated in hospital has a legal right to be informed of the nature of the illness, the alternatives of treatment, the reason why a particular treatment has been chosen, the drugs that are to be used, their side effects and the likely interaction. All this information must be written in the notes in a legally correct and legible manner. Of course, relevant history and findings must also be recorded to make the notes legal. If rural general practitioners are seeing 40 to 50 plus patients a day and working a 12 hour day, they are unlikely to have time to write this much documentation and, as patient care comes first, the doctor is unlikely to be compliant in keeping legal notes.

I guess this is the sort of thing that the Hon. Nick Xenophon is referring to when he says that doctors are being irresponsible. This is the dilemma that faces every general practitioner: do they practise clinical risk management, see only 25 patients a day and ignore the risk of not adequately following up patients or not seeing patients in an emergency? The level of care is not taken to be what a reasonable general practitioner would do in similar circumstances but what the judge on the day considers to be appropriate treatment.

I was not going to read all this but, in the light of the interjections that I have been receiving from the Hon. Nick Xenophon, I think he needs to understand the experience that doctors have out in country regions.

The idea of having a limit to payouts similar to our workcover system was therefore advocated by many of the people making submissions. Accordingly, the committee in its final recommendations has recommended that a workcover type system with the capping of medical compensation claims be introduced. Through my work as the Democrats health spokesperson, I know that the AMA had discussions with the Minister for Human Services some time ago about this, and I look forward to hearing a positive response from the minister to the committee about this recommendation.

Additionally, the suggestion was made to us in evidence that the courts need some guidance in ordering payouts, so that a one-off lump sum is not the only way to make the payout. The point made to us was that a large lump sum can be spent at a rapid rate on a person who has been subject to some form of medical malpractice, with no money left to fund the extra services that might be needed to support someone with disabilities later in life. Accordingly, the committee has recommended that the suitability of compensation settlements paid as an annuity or pension, rather than a lump sum, be investigated.

Without appropriate people to deliver health services, the structures and the equipment are all but meaningless. Consequently, a great deal of the evidence that the committee took was about doctors, nurses and allied health professionals, with the general lament that there were not enough of any of them. The reasons range from health professionals wanting to live in the metropolitan area so that their children can have access to the education and services they believe are desirable to not wanting to have to be an expert on all medical conditions, as rural doctors have to do. That there is a shortage of doctors in rural areas in Australia is now a truism. The progress of the committee's inquiry revealed to me something of which I had not been previously aware, that is, the enormous amounts of money being metaphorically `thrown at doctors' to either attract them to or keep them in the regions.

Since the release of the Social Development Committee's report, I have met with Dr Paul Beckinsale of the Royal Australian College of General Practitioners to discuss some of the recommendations, and he has presented some interesting information to me about the training of GPs in South Australia. Unfortunately, the college did not provide information or present evidence to the committee so that what I raise now, although it has implications for rural health, was not part of our deliberations. Without going into complex details, Dr Beckinsale has explained to me that because of the formula used South Australia gets only 6.7 per cent of the total pool of the commonwealth's GP funding package. Prior to 1995 the Royal Australian College of General Practitioners was training 70 GPs per annum in South Australia, but it has now been reduced to 33 this year. If you are a medical student graduating in South Australia and you want to be a GP, your best bet is to move interstate if you want to get training to become a GP.

Clearly, this must have an impact on the number of GPs who are available to go out into country areas. Given the reasons doctors provided for their reluctance to go out into these regions, how much impact this reduction in training money is having is unclear. While many people think `doctors' when they hear the word `health', a great majority of health delivery comes through other staff, including nurses, midwives and allied health professionals, and without them the health system would come to its knees.

The unsung heroes in some of the remoter areas of South Australia are the nurse practitioners. These are registered and very experienced nurses who often operate on their own in small rural and Aboriginal communities. The committee recommended a widening of the role and responsibilities of nurse practitioners. Specifically, in recommendations 11, 12 and 13, we said that there needs to be more training and induction of nurse practitioners; that the federal government should give a restricted provider number to enable them to order an appropriate range of investigative reports; and also that the federal government give nurse practitioners limited and appropriate prescription rights for pharmaceuticals.

When the AMA became aware of these recommendations, it made public statements attacking the committee for having made the recommendations. Nevertheless, despite everything that I have heard from the Royal Australian College of GPs, and having accepted that there is a funding disparity for GPs that might reduce some of the pressure in South Australia if there was equity, there are some communities which, because of their small size and remote location, would never be permanently serviced by a GP. These recommendations are not open slather, and I stress the word `appropriate' that attaches to both the recommendations about the restricted provider number and the prescribing rights.

I greatly admire the work of nurse practitioners and believe that we should support them to do their job well. It befits their professionalism. I have had one letter from a nurse saying that this recommendation should not occur because `nurses do not want that responsibility'. I acknowledge that there are some nurses who do not want that responsibility. Some nurses choose to be enrolled nurses rather than registered nurses because they do not want that extra responsibility. But there are some registered nurses who see that they can deliver these services and who want to be able to deliver these services outside of the constraints of a medical model of health care. If we free up the system for them there will be benefits for those living in remote communities and there are particular ramifications for those living in Aboriginal communities.

I point out that, even in a community which is large enough to sustain a full-time GP, issues arise where a nurse practitioner's having prescribing rights might be far more acceptable in a smaller community. As an example, I refer to a hypothetical example of a woman who is on the school council with her local GP and whose daughters play on the same netball team. That woman may not feel comfortable going to see the same man as her medical practitioner and talking about her contraceptive needs or having him take a cervical smear.

I make it clear what the current situation is in relation to nurse practitioners. They can undertake cervical smears, but they do not have the right to authorise that the smear go to a laboratory to be checked or tested. They cannot sign the laboratory form. It is useless their being able to do the smear test and then not being able to send it on to a laboratory.

Other health professionals that were of concern in evidence we were given included physiotherapists, podiatrists, dietitians, psychologists and health educators. The Yorke Peninsula division of the Rural Division of General Practitioners in South Australia drew attention to a shortfall which affects one of the federal government programs it runs. It stated:

Because of the federal government enhanced primary care initiatives, the lack of allied health workers needs to be addressed urgently as this whole package is built on the assumption that GPs have community health workers to case conference with, institute care plans, do home assessments. I do not think that the general public will be pleased if they know that these initiatives cannot be acted upon because their state fundholders cannot see the value in dollar terms of good preventative care to keep people out of hospitals and aged-care facilities.

I sometimes wonder whether the government really understands what primary health care is but, if the Yorke Peninsula division was making these observations in its area, clearly there would be problems elsewhere.

We made no recommendations on midwives, but a number of hospitals and health services told us that there was a shortage of midwives in their regions. The observation was made that there is a problem because many of the midwives are expected to be multiskilled or have generous nursing skills. Of course, not all midwives want to be involved in aged-care and mental health and there needs to be some way around this. I think we need to respect the midwives' right to be just midwives if that is what is needed. The solution may be assistance and extra training for those women who have midwifery skills who want to build on and develop other skills.

As the Hon. Ron Roberts observed, mental health is probably the major issue in the regions, and that appeared to be the case wherever we went and whatever evidence we took. We did note, for instance, that in some ways regional hospitals were better off than metropolitan hospitals. We came across one regional hospital, for instance, where there was a six to eight weeks' wait for a hip replacement operation, whereas in the metropolitan area it is about 18 months to two years. On the other hand, there was also another rural hospital that had about a five year wait for hip replacement operations.

In the area of mental health, almost every hospital and health service made some comment about the lack of back- up. This was an area where we took the evidence very seriously, and we made seven recommendations on mental health. Recommendation No. 22, which was the crucial one for me, states:

A number of hospitals within each region be resourced with appropriately trained support staff and have a designated room, or a room that can be adapted safely and quickly, to care for a person suffering from an acute mental episode.

The Northern Yorke Peninsula Health Service referred to the current situation and states:

So often NYPHS has transferred patients under detention to metropolitan health services with the outcome for that person being very unsatisfactory. The isolation and increase in anxiety is often unwarranted and the detention order is lifted and the patient discharged back to the local community only to be readmitted to hospital with the same problem.

One must query the value of having done that. The submission from the Southern Yorke Peninsula Health Service and Central Yorke Peninsula Hospital about mental health was at least very angry, in part, and states:

It would not be an overstatement to say that there is a crisis in our lack of capacity to provide proper care to those with mental illness. On Yorke Peninsula there are three mental health nurses to provide services for a population of over 23 000 people. They are supported by a very much part-time visiting clinical psychologist and occasional visits from a private practice psychiatrist. We are extremely disappointed that the promised reassignment of resources to the community as a result of de-institutionalisation has only been realised in a token way in rural areas such as ours. The mental health nurses are highly stressed and at risk of burn-out, endeavouring to cope with a workload which is impossible for them to meet. We are frequently only able to meet crisis care needs.

The Mental Health Advisory Group for the Northern and Far Western Regional Health Service raised the issue of access to psychiatrists. Its submission states:

In the 1993 report, `Country Mental Health Services for South Australia: A Framework for Service Delivery', the recommended allocation of psychiatrists in Port Augusta is `three sessions a week'. Currently it receives 1½ days a month of consultant psychiatrist time, soon to be reduced due to an extended period of annual leave. There is no other specialist psychiatric service in the region. Perhaps some of the federal funding being offered (and not being accessed) to attract rural and remote GPs could be diverted to support an increase in visiting psychiatrists to our rural and remote regions.

Sexual health was another issue with which the committee dealt and those who have read the report will note that recommendation 33 states:

Additional funding be allocated by the state government to enable the Sexual Health Hotline information referral and counselling service to operate seven days a week, 24 hours a day.

This service offers advice about contraception, sexually transmitted infections and sexuality information, which can be extremely important in rural areas where we know, for instance, there is a high suicide rate or at least a high rate of attempts at suicide by young gay men. When is the sexual health hotline open? Monday to Friday, 9 a.m. to 1 p.m. It was observed during the taking of evidence that this is the time when most of the people who might be wanting to access it would be at school. I was very pleased last week to attend the 30th birthday celebration of Shine SA at which an announcement was made of government money to that organisation. I have not had a chance to speak with Shine SA about how it intends to use the money but I hope that part of it will be able to turn the sexual health hotline into a seven day a week, 24 hour a day service.

The impact of regionalisation was another of the terms of reference. For those hospital boards where the hospital had been declared to be the regional hospital there was satisfaction with regionalisation, but for those hospitals that were lower on the pecking order there was dissatisfaction. The committee opted out of dealing with this issue and it was the one recommendation I felt we did not deal with properly because it became political. The majority of committee members on the day we reviewed the recommendations were government members and they did not want to see any criticism of the government. Recommendations 29, 30 and 31 are couched in very non- threatening terms. Recommendation 29 states:

The state government takes steps to ensure regional autonomy and avoid duplication of functions in the central offices of the Department of Human Services.

The state government reassess the validity of casemix funding for regional areas and make adjustments if required.

Some of the hospitals, I think, felt constrained with what they said. I certainly know that what we received in writing did not always reflect some of the private comments that have been made to me as the Democrats health spokesperson. Nevertheless, one needs to read between the lines. The submission presented by the board of directors of the Port Lincoln Health Services states:

As the committee would be aware, regionalisation of health services was a South Australian Health Commission initiative that was implemented approximately five years ago. The philosophy behind this model of health service delivery was to empower local communities to take ownership of their health needs and develop and enhance local services. It was also intended that the resultant structural changes to the system would not add any new layers of administration to the process, but rather savings would be made from downsizing the previous country health services division in the Health Commission, and these savings would be used to provide additional services to rural communities. Consequently the intent behind regionalisation appeared to be sound and therefore generally supported. Whether it has achieved its objectives is unclear and the board therefore suggests that an independent evaluation of this model of service delivery be carried out.

I stress that word `independent' because that is the word that the majority on my committee would not include in its recommendations. It wanted the government to be able to review. The Barossa Area Health Services, I think, was a little more scathing between the lines than the Port Lincoln Health Services. The Barossa Area Health Services included part of the response it had sent to the Minister for Human Services in relation to the Human Services Department's document `Evaluation of Regionalisation in Country South Australia 1998'. At that time the Barossa Area Health Service told the minister:

Although the Barossa Area Health Service has fully supported the implementation of regionalisation, there appears to have been little achievement into its primary goals. It is considered that the evaluation report is biased in its findings and conclusions and has not taken an objective and arm's length view of the process. A critical analysis which identified the positive and negative factors and issues, that both facilitated and hindered meeting objectives, would have been more constructive in assisting a credible evaluation process. The implementation of regionalisation has resulted in the following for the Barossa Area Health Services Incorporated: (a) a loss of over $100 000 in 1998-99 from patient care to support a regional bureaucracy; (b) an additional layer of bureaucracy has been implemented with a resultant slow- down of decision making and reduction in delegations and autonomy for local health boards; (c) a reduction in local board and community input into the representation and development of local health services, i.e., the process has acted as a filter in the access and development of local health services. It is suggested that, as we have progressed a further two years on from the report time frame, it may be opportune that a subsequent evaluation be undertaken. To achieve a truly meaningful evaluation it should be undertaken by an independent reviewer and have a broad input from all health care providers involved, including local health unit boards, non-government organisations, etc.

That was from a letter the Barossa Area Health Services sent to Dean Brown. Again, it stresses the need for an independent review. In its actual submission to the committee, the Barossa Area Health Services stated:

I must again reiterate my board's support for the regionalisation concept, however a number of significant issues provide ongoing concern: reduction in dollars committed to patient care- approximately $5 million dollars per annum; new layer of bureaucracy; no reduction in staffing for Country and Disability Services Division of DHS; additional 50 plus FTE in regional offices; increase in duplication; confusion of responsibilities; increased centralised control and reduction in local community involvement.

So, whilst I think most of the boards feel that their hands are tied and that they have to say that they support regionalisation, the extent of that support is questionable.

I note the Hon. Terry Roberts' comments about Aboriginal health. The committee decided that this issue needed to be investigated in its own right, that it is an extraordinarily complex matter, one which no state or federal government has been able to solve over a period of years. I would welcome the opportunity at some stage to take this issue on as a complete reference. Many of the recommendations that we have made, however, will have positive effects for Aboriginal communities if they are acted upon. I am happy to support the motion.