Coalition Minority Report
1.1
The Coalition seriously questions the need for yet another layer of
centralised health bureaucracy in the form of Commission to be established by
this Bill. The Commission already exists within the Department of Health and
Ageing and is highly regarded within the health care standards sectors. The
establishment of a new stand-alone Commission will cost the taxpayer millions
of dollars supplying many services already considered to meet international
best practice.
1.2
The setting of standards and accreditation is already being performed by
an independent not for profit organisation, the Australian Council HealthCare
Standards (ACHS). Responding to a Question on Notice, ACHS surveyed its members
and found that 66% of them were "satisfied to extremely
satisfied" [1] with the work and performance of the ACHS.
1.3
In the same survey 98% of the membership of the ACHS supported the following
proposition:
I agree with the
ACHS’s view that the adoption of an existing set of standards (that would still
meet the Commission’s objectives) as the national standards would be preferable
to introducing a whole new set of standards.[2]
1.4
ACHS was established in 1974 with Federal government support and is one
of only four organisations that meet the international accreditation
requirements of the International Society for Quality in Health Care. Linda
O'Connor of ACHS said:
Over the last 36 years
ACHS has extensively developed and implemented the areas outlined in part 2,
clauses 9, 10 and 11 of the National Health and Hospitals Network Bill 2010.[3]
ACHS President, Professor Peter Woodruff said:
I also think it is a
shame if the commission wastes too much of its time and effort on re-inventing
the wheel.[4]
1.5
Whilst supporting the establishment of the Australian Commission on
Safety and Quality in Healthcare, Carol Bennett of the Consumers Health Forum
of Australia sounded a warning on wasteful duplication:
... The ACHS is obviously one of the key bodies—who have
already been working in this space and have already spent many years developing
standards and guidelines and have also looked at engaging consumers,
particularly in the mental health area, in assessing how those standards are
applied. So it will be important, I think, to ensure that there is not duplication
of effort between the ACHS and the commission in their work. [5]
1.6
Submitters were also concerned that there should be a measure of public
consultation in regard to its provisions before the Bill became law. In this
regard, Associate Professor Woodruff (ACHS) said:
"I would just hate the wording of this bill to establish
an authority that did not really have to engage people that have been working
in this field with a good track record for decades" [6]
1.7
The Coalition questions the need for this Commission, given confusion
within the Department of Health and Ageing on the differing roles of ACHS and
the Commission. Although the Department has subsequently corrected the record,
in asserting the need for the Commission as outlined in the Bill, the
Department argued that there were significant gaps in the health care national
standards:
The Commission will be responsible for developing national
standards across all healthcare settings. The Commission is developing a
nationally consistent set of safety and quality accreditation standards that
can be applied across all healthcare sectors, not just restricted to hospitals,
primary health care or mental health. Conversely, the ACHS’ role is focused
primarily on the accreditation of hospitals, including the development of
hospital accreditation standards, and does not extend across the entire
healthcare system. [7]
ACHS subsequently pointed out:
ACHS’ role is significantly broader than hospital
accreditation. ACHS develops standards and provides assessment for Community,
Primary Care and Multipurpose Services, Day Hospitals, Mental Health, Drug and
Alcohol, Justice Health and Oral Health Services. [8]
1.8
Submissions also expressed concern about the lack of detail about
the approach the Commission would take to accreditation with concern that it
could be "...a 'tick the box' certification exercise, [rather] than a
continuous quality improvement exercise."[9]
1.9
Submitters also expressed concern that the standards in the mental
health area were not covered in the health reform process. Dr Darryl Watson,
Treasurer of the Royal Australian and New Zealand College of Psychiatrists,
said the process "continues to neglect the needs of those with
mental illness". [10]
Dr Watson went on to say:
"The college believes there is a need for specific focus
on the special needs of the safety and quality issues in the mental health
sector. Closer engagement between the commission and mental health consumers
and carers would improve the influence of the commission on practice in this
sector. The provision of this focus is not covered by this bill." [11]
1.10
The proposed reforms also contain provisions for the future
establishment of two more bodies, the Hospitals Pricing Authority and the
National Performance Authority. This will require further layers of
bureaucracy, again incurring a significant cost. Whilst supporting the
establishment of the authorities, Professor Woodruff from ACHS said:
"...perhaps of more critical importance is the structure
and function of the Independent Hospital Pricing Authority and the National
Performance Authority...we believe that it is so important that it should be
available for public scrutiny and debate prior to the passage of the
Bill." [12]
1.11
Dr Watson, RANZCP, told the inquiry:
One of the inherent problems when you are talking about
safety and quality is that there is a benefit in having separate independent
authorities but in actual fact they need to mesh throughout the whole process.
So there is a risk, when considering these things separately, that you
reinforce the idea that safety and quality are addressed as a checklist or a tick
box rather than being an integral part of services or, in this case, an
integral part of reform and future planning. [13]
and,
I think there is a concern that when you look at the safety
and quality in a narrow focus it is easy to tick the boxes, go through the
checklist and conform with whatever the standard is, but it is much more complicated
than that. If you were looking at safety and quality as part of the
effectiveness of health care, you could look at performance and pricing as
efficiency, and you need to balance those things. The other concern is that you
could end up at a local level with an imbalance around some of those efficiency
and effectiveness issues that need to be tied together.[14]
1.12
A number of submitters said it would be preferable to introduce
legislation the Commission, the Hospital Pricing Authority and the National
Performance tribunal as a package. It's been argued that there is a danger in
the separation of health and safety from pricing and efficiency, Dr Watson,
Royal Australian and New Zealand College of Psychiatrists:
...having those key bills aligned would seem to give more
benefit than having them apart. I think my answer was that as long as the good
work of the commission is able to continue and we are not talking about years
of delay, our preference would be that those things be aligned and we try to
reduce the chance of there being cracks in the system or parts that are missed
across those bills. [15]
This was supported by the submission from the Consumers
Health Forum of Australia:
We have noted the argument in several submissions that
legislation to establish the commission should be considered in conjunction
with consideration of legislation to establish the National Performance
Authority and the Independent Hospital Pricing Authority. Given the likely
interrelationships between these three bodies, that is an approach that makes
sense to us. [16]
1.13
Some submissions have suggested that the key reform that is required is
the establishment of an independent regulator to enforce compliance with the
quality healthcare standards already established by such bodies as the
Australian Council on Healthcare Standards (ACHS) and other medical
professionals.
1.14
One of the most worrying aspect of this proposed Bill is the total lack
of detail as to how the Commission would go about its work. There is no detail
as to how the new body would perform the most fundamental facets of its operations, that
is, how they would measure performance and what powers they would
exercise. Again in evidence to the inquiry Associate Professor Woodruff said:
...we must work out how the commission is going to have teeth,
how performance is going to be measured and how compliance is going to be
assured. [17]
This view was supported by comments from the Consumers Health
Forum of Australia, who said:
However, it appears to us from this bill that compliance with
the standards and guidelines developed by the commission will remain voluntary.
If we are to aim for the highest standards of safety and quality in health
care, and if the commission is to drive this, somekind of incentive or
sanction needs to be in place to encourage or enforce some kind of compliance.
Otherwise, we run the risk of seeing a commission developing high-quality
standards and guidelines which have no value because they are not adopted by
our health services. In that instance, it becomes an expensive and irrelevant
body. [18]
1.15
ACHS added:
The ACHS noted that in the past the ACHS has had the dilemma
of being both the teacher and the policeman. i.e.: the ACHS has been both the
developer of standards and the accreditation service provider. [19]
1.16
In the absence of any clear delineation of the particulars of the
enforcement methods and strategies to be employed by the proposed Commission,
submissions raised concerns about the lack of public debate on the commission's
proposed approach to enforcement, especially if financial penalties and/or incentives
were used to effect compliance. Associate Professor Woodruff said:
"One way of enforcing control is financial.....it is open
to manipulation and anything other than safety and quality as the driving
force. And that is the crux of the problem." [20]
1.17
In regard to what sanctions or rewards the Commission may use to achieve
the desired standards of health and safety, there was also some concern that those
standards need to be set in a context for some healthcare providers facing the
particular challenges of remoteness and distance. We note, in particular, the
submission from the Aboriginal Medical Services Alliance Northern Territory
[AMSANT]:
Some of the blockages to accreditation for ACCHSs are related
to infrastructure deficiencies which will require significant government
funding to overcome. Therefore ACCHSs cannot always meet national standards,
possibly including safety standards, due to lack of quality infrastructure and
limited funding support from government. [21]
1.18
In regard to performance tests of clinical performance to be employed by
the proposed commission, concerns were expressed that they were inadequate and
that the Commission proposed to use the very screening that failed to detect
the clinical performance of Jayant Patel at Bundaberg Hospital.
Professor Woodruff said:
One of the problems is that administrative data, particularly
the ICD-10 coding system, is grossly inadequate for measuring outcomes. For
instance, Patel was not an outlier on his ICD-10 profile. The research group at
Flinders University, looking into standardised hospital mortality rates, has
done a comparative study based on using administrative data and the more
definitive technique of studying case notes—which is laborious, time consuming
and expensive—and found that there is very little correlation between the two.
But this new entity will have, as one of its guidelines or one of its
measurable, standardised hospital mortality. These are the sorts of issues that
really need to be debated by people who know what is going on before they are
all set in stone. [22]
1.19
The stated intention of this Bill, according to the Government
and the Department of Health and Ageing, is to continue reforms of the
Australian healthcare system to save the taxpayer money and to improve the
health and safety of clients of the system. However there are some serious
shortcomings in the approach that this proposed Bill does not resolve. In
evidence to the inquiry, Martin Laverty, CEO of Catholic Health Australia,
said:
"Our obvious disappointment is that the opportunity
existed for some harmonisation around these matters and the bill has not
achieved that.” And "...we would be seeking harmonisation and indeed the
removal of the duplication, the removal of the cost to the healthcare system
that exists through these multiple reporting frameworks that this legislation
unfortunately is simply replicating." [23]
Mr Laverty also raised the difficulties some national not
for profit or charity healthcare providers have with the layers of regulation
and reporting that already exist in our healthcare system...
A national group like St Vincent’s Health Australia or the St
John of God Health Care group that operate public and private hospitals across
state boundaries continue to be subjected to different reporting regimes, at
cost, in each of the jurisdictions within which they work. That is not
efficient healthcare. [24]
This issue was also of concern to the Aboriginal Medical Services Alliance
Northern Territory [AMSANT], who in their submission to the inquiry wrote,
"The proposed permanent Commission will consider binding
standards across primary health care, but this will require coordination with
relevant standards setting bodies for primary health care including the RACGP
and other bodies such as QIC and ISO. This coordination will ensure that there
is not further complexity with services needing to meet two or more different
sets of standards in a workplace rather than just one. ACCHSs already operate
in a complex and highly regulated environment: national standards set by the Safety
and Quality Commission should not to add to this complexity. [25]
1.20
Other concerns have been raised about the makeup of the Commission board,
the wording of the Bill and the absence of explicit references to key
stakeholders the proposed Commission should consult with. Some submissions
expressed concern that the legislation, as it stands, doesn't make it clear as
to whether the Board would include consumer representatives or even key health
care professionals, Martin Laverty, CEO Catholic Health Australia,
...there is not necessarily a recognition that a majority of
surgical procedures in Australia are performed in the private sector and that
it would be appropriate that non-government representation be considered in the
event that representation is to be given to consumers and potentially others. [26]
The Consumers Health Forum of Australia noted:
Broadly speaking, our main concerns relate to, in particular,
the need for specific reference to consumer engagement and identification of
health consumers as a group that must be consulted as the commission undertakes
its functions. We are concerned that the bill enables specific consultation
with clinicians but not consumers. To simply state that the public must be
involved in consultation is not good enough. We note that many other
stakeholders have made this point in their submissions. Every study around the
world has supported the involvement of consumers in health decision-making as a
way of ensuring that you get health system improvements. Secondly, there is a
need to clarify the commission’s functions and whether they extend to include
allied health professionals and allied health services.
Finally, there is a need for greater clarity around how
consumers will be represented and supported on the commission’s board. [27]
1.21
The issue of the make up of the Commission Board was of sufficient
concern for there to be calls for amendments to this Bill to ensure a proper
representation of key stakeholders on that Board, Martin Laverty said:
So, if there were to be any amendments to this legislation
that would speak to the proposed governance arrangements, recognising that
provision has been made for representation of skill sets, it might also be wise
to formalise a representation of different bodies with that background.
And,
If there were to be amendments, it might focus on ensuring
that there was NGO and consumer representation. [28]
1.22
The Aboriginal Medical Services Alliance Northern Territory also had
this to say in their submission in referring to Section 20 of the Bill:
AMSANT is therefore of the very strong view that one of the
potential "attributes" the Minister should take account of is for a
potential Board Member to have "substantial experience or knowledge; and substantial
standing" in "comprehensive Aboriginal primary health care"
under Section 20(3) of the Bill. [29]
1.23
This point was also taken up with particular reference to mental health
in the submission by the Royal Australian and New Zealand College of Psychiatrists
whose Treasurer Dr Watson told the inquiry:
The bill mentions the term ‘the public’; we would expand that
so that there is some mandated presence of consumers and carers. There are a
number of reasons for that. All aspects of the health system seem to work
better when they are sitting at the table with consumers and carers. There is
something about that that focuses the mind; there is something that those
people bring which is novel, creative and helpful around that path. It maybe,
that specifically noting the representation of that group is something that
could be added to the bill, in addition to the notion of ‘public’. [30]
And,
In any reform aiming at improvement in health you are looking
at improved outcomes. I agree with you that that should be a focus." [31]
1.24
In reference to the title of this Bill there has also been
comment that it is clumsy and potentially confusing, Dr Watson, Treasurer,
Royal Australian and New Zealand College of Psychiatrists submitted:
The college supports the establishment of the Australian
Commission on Safety and Quality in Health Care as a statutory, permanent and
independent authority as proposed through this bill. It is, however, suggested
that the title and the object of the bill be revised to better reflect what is
being considered under the bill and to distinguish it from the establishment of
other bills that will be introduced under the National Health and Hospitals
Network Agreement. [32]
Recommendation 1
Given the cost, the lack of focus and unclear governance, and the
potential for duplication, the Coalition urges the Government to withdraw this
Bill.
Recommendation 2
If the Government persists, the Coalition strongly
recommends that this legislation to establish the Commission be deferred until
the legislation for and purpose of the Independent Hospital Pricing Authority
and the National Performance Authority has been fully developed.
Senator Judith Adams Senator
Sue Boyce
LP, Western Australia LP, Queensland
Senator Concetta
Fierravanti-Wells
LP, New South Wales
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