Senator SIEWERT (Western Australia) (6.01 pm)—The Australian Council of Safety and Quality in Health Care was first established as a non-statutory body in 2000 in response to a study by the then Commonwealth Department of Human Services.
The study showed an adverse event rate of 16.6 per cent across public hospitals. The council was asked to lead national systematic approaches to improvements in the safety and quality of health care with an initial focus on reducing errors. The Australian Commission for Safety and Quality in Health Care, as it is now, commenced operations in January 2006. It was given a five-year program to tackle patient rights, accreditation of health services, medication safety and hygiene. The commission was asked to report to the health ministers and link up with health departments and other government and non-government bodies. At the time, it was envisaged that a commission would have clear mechanisms to link with, and participate with, jurisdictions and key stakeholders. The commission was to be responsible for providing robust advice to the Commonwealth, state and territory health ministers and informing the development of national safety and quality strategies.
Notable achievements in this period include the Australian Charter of Health Care Rights, the National Patient Wristband Standard and the development of a national approach to surveillance of hospital-acquired infection rates. I also mention the national falls prevention guidelines and the development of the guide to clinical handover improvements. These were all endorsed by Australian health ministers. In June 2009, the National Health and Hospitals Reform Commission recommended that the commission should be established as a permanent body.
This brings us to this particular legislation, the National Health and Hospitals Network Bill 2010. The Greens believe that safe, high-quality health care is imperative to any sensible health reform agenda. The commission will be responsible for developing and monitoring quality and safety standards, working with clinicians to identify best-practice care and ensuring the appropriateness of health care. The commission will also provide advice to the Commonwealth, state and territory governments about standards that can be implemented on a national level. It is important to note, however, that national standards will only be implemented if all of the states and territories are in agreement.
The Greens are concerned that this in fact may delay implementation of a nationally consistent approach. Compromise may also be required to reach agreement on national standards. This highlights one of the deficiencies of the commission, and that is its lack of power. It provides advice on national standards for states and territories, yet this advice is only implemented on the agreement of all parties. It has a monitoring role but not a regulatory role. Further, compliance with standards is voluntary. Although I understand the Commonwealth may make compliance with standards a condition of any grant, there is concern about the actual powers or role of this commission.
States and territories cannot even agree on national data collections, reporting requirements, definition of sentinel events and a universal charter to be used for patients, so I do not hold much hope for them being able to reach agreements on national standards for safety and quality in the short term. The states, which are considered to be world leaders in certain areas, are going to be reluctant to compromise of course on areas where they consider themselves to be experts. We are concerned that there may be some aspects of their standards being ‘dragged down’. Of course, we also recognise that we need to ‘drag up’ low-performing regimes. We flag this as an issue and we will keep an eye on that.
If there is a delay in reaching agreement on standards, this will affect when implementation can commence. Under the agreement with the states, the states are the ‘system managers’ for public hospitals, including for planning and performance. Presumably, this would extend then to ensuring that local hospital networks implemented these national standards. While I suspect that most local hospital networks would implement the relevant national standards, as it would be considered in the public interest to do so and difficult to defend if they did not, the issues around accountability between the local hospital networks and the state health departments varies between state to state and has not been fully resolved.
The Greens will be moving a number of amendments to the legislation. These came directly out of concerns that have been raised with us and also from concerns raised at the Senate Community Affairs Legislation Committee inquiry into this bill. I will go through some of those concerns. The legislation states that commission standards, guidelines and indicators will be developed in conjunction with clinicians, professional bodies and consumers. During the inquiry a number of submissions from witnesses identified the issue that a clinician was often seen as a doctor. The National Primary Health Care Partnership stated:
While no definition of the term ‘clinician’ is provided in the context of the bill, the NPHCP wishes to emphasise that it is important this term is recognised as applying to nursing and allied health professionals as well as medical doctors and that these professionals are consulted in the development of standards, guidelines and indicators relevant to their scope of practice.
The Greens have some amendments that clarify the definition of ‘clinician’ so that it means more than perhaps what can sometimes be a narrow interpretation of that word. Our amendments define a clinician as an individual who provides diagnosis or treatment as a professional. This can be a medical practitioner, a nurse, an allied health practitioner or an Aboriginal health worker. We believe this makes the legislation much clearer, and it is clear that all these medical professions are involved.
The Senate inquiry also raised the concern that participation of not just public consumers but also carers on the board had to be made much clearer. The Greens have proposed amendments that provide for the commission to consult with consumers and carers before formulating standards, guidelines or indicators. We understand that representation is one thing but this is also about the way it translates to genuine engagement with the consumer. Our amendments address this issue.
The Consumer Health Forum outlined during the Senate inquiry the need for consumers to be involved at all levels of standard setting and guideline setting. While it has been great that there has been a consumer commissioner on the current body, a single person is not the answer to ensuring that you are covering the needs of all consumers and carers
With regard to the involvement of consumers, the Greens also have an amendment that deals with patient confidentiality. During the Senate inquiry the issue of clarification of the meaning of consent was raised. The Consumer Health Forum welcomed the provision requiring the commission not to publish or disseminate information that would be likely to enable the identification of a particular patient. However this provision would not apply if consent has been provided. The Greens have an amendment that changes this to ‘informed consent’. We had a discussion during the inquiry about informed consent. This was to make sure that the consumer who is able to give consent can do so in an informed manner and is fully aware of the implications of providing consent.
The Greens share the concerns raised during the Senate inquiry about compliance. This will be crucial in terms of enabling the commission to achieve the substantial ambitions that have been set out. The Greens believe that this commission could be effective, like the National Institute for Clinical Excellence in the UK, in both improving quality and lowering the costs of services through improved work practices. However it is worth remembering that since 1995, when a definitive study was undertaken on adverse events in New South Wales and South Australian hospitals, there have been a lot of committees, studies and money spent on quality and safety but little improvement.
After examining more than 14,000 hospital admissions in New South Wales and South Australia, the national cost of harm from health care in our hospitals was estimated at $4.17 billion per annum. That $4.17 billion estimate represented 23 per cent of recurrent costs in all hospitals at that time. Assuming the same percentages of mistakes in 2010-11, the cost would now be more than $11 billion. This would be a conservative estimate because complexity of cases has increased significantly since 1995. For example, the ‘redo’ rate for joint replacements is 25 per cent. The estimate of $11 billion does not include mistakes in the non-hospital sector or the cost to the community of death and permanent disability.
As the Consumer Health Forum noted in the inquiry, there are a number of layers to all of this. There are the state governments and their role, there is the accreditation system and there are the different standards bodies, and they are all involved in this equation. The Greens believe there need to be some additional mechanisms built into the health reforms, and we look forward to seeing progress made on the development of a robust, transparent and effective performance and accountability framework for the Australian health system.
As we understand it, this framework could be used to set out clear performance standards in health care, and it could propose mechanisms for governing compliance. The Greens understand discussions are yet to specify how the framework will provide Australians with greater information about the performance of health and hospital services, but that it will include standards developed by the Australian Commission on Safety and Quality in Health Care. It will be interesting to see whether there is any provision in the National Performance Authority legislation for an accountability framework, and in particular how its roles and responsibilities would complement those of the safety and quality commission. In other words, we are looking at how these two particular bodies intersect to ensure that one complements the other.
The Greens note the submission from Choice to the NHHRC last year in which they supported the introduction of public performance reporting in the health system as a measure to drive improvements in quality and safety. They wish to see reporting developed for all aspects of the health system, not just hospitals.
The framework for implementation of national standards will be a crucial part of the reform puzzle, but it may also further compound matters as this will be the responsibility of the local hospital networks rather than state and territory health departments. As yet, the accountability frameworks between local hospital networks and state and territory health departments have not yet been defined and will vary by state and territory. Furthermore, the role of private hospitals under the local hospital networks is yet to be clearly defined and will be resolved on a state by state basis. This may further limit the extent to which a national approach can be implemented.
During the Senate inquiry it was noted that emphasis on representation of the board members provided for experience in general management of public and private hospitals but not specifically for expertise related to management of primary healthcare provider services —these could include general practices and community health services. Too much emphasis throughout the health reform process has been on hospitals and the Greens believe that much more should be done to focus on prevention measures, primary health and community services to keep people well and out of the hospital system.
We have an amendment that includes provision for the appointment of board members to include expertise relating to the management of general practice and primary healthcare services. The Mental Health Council of Australia noted in the Senate inquiry:
It is disappointing that the Bill does not make provision for specific expertise from health consumers and carers or mental health professionals as part of the Board of the ACSQHC. Such provision would be a significant step in ensuring that the activities of the Commission reflect the needs of mental health consumers and carers and would assist the Commission to better address the acute safety and quality needs in the mental health system.
The bill will be subsequently amended by parliament to establish two new statutory agencies—the Independent Hospital Pricing Authority and the National Performance Authority. However, the bill is silent on how these agencies will work together. This will be an important issue as the three agencies will likely be collectively responsible for improving the performance of the healthcare system and, more broadly, governance arrangements for health reform.
There is a growing awareness that patient care and chronic disease management require a multidisciplinary approach across a range of health sectors. The bill provides for consultation on the development of guidelines, standards and indicators, and consultation on the development of a national model accreditation scheme. The department advised the Senate inquiry that the commission has placed considerable emphasis on broad stakeholder consultation in the development of key projects. In particular, consultation with respect to the development of standards has been framed within a seven-stage methodology that includes different mechanisms through which stakeholder groups contribute and draft standards are tested.
The Greens have concerns about voluntary compliance with the guidelines, standards and indicators developed by the commission and, as we have said, there have been many concerns raised about whether the commission or reform process will have sufficient teeth to implement standards on a national basis. The Australian Nursing Federation has suggested that the lack of incentives to implement the proposed standards could lead to inconsistencies and a failure to ensure improvements in quality. The AMA has also noted the lack of obligation for state and territory governments to comply with guidelines and standards from the commission. As we have said, we will be pursuing provision for compliance in the National Performance Authority legislation and through the other legislation we are yet to see on finalising the health reform process.
During the Senate inquiry, Professor Smallwood noted that the commission is ‘expected to make things happen in a way its predecessor could not’. He suggested this could be achieved through high-quality data on safety and quality on a national level to be used for national benchmarking purposes. The Greens would support this approach. Australia does not have a nationally consistent dataset for hospitals. We believe that public pressure and accountability on performance could be a significant lever in improving standards and we hope to see measures that will provide for this in future legislation; otherwise, we will seek to amend subsequent legislation to ensure this happens.
Finally, the Greens note research from the UK and the US which has shown that consumers had made little use of performance reports in places where they were available. The problem with the reports was that they are based on non-standardised measures and are not user-friendly. The way information was presented or ‘framed’ strongly affected whether consumers understood it, how it was evaluated and whether they used it. The research found that consumers cannot be expected to weigh up measures against a wide range of indicators to rank providers. Most presentations of comparative information are based on the assumption that consumers know what is important to them and where their self-interest lies. For example, it is usually assumed that people have fixed ideas about what is important in healthcare quality and that they can pick and choose from among different performance measures displayed in a comparative report. However, both theory and evidence suggest that these assumptions are faulty. When people are in a situation in which they must sort through complex, unfamiliar and important factors to make a choice, how that information is framed and packaged will determine to a large degree what information is actually used in that choice.
As performance reporting develops, consideration will need to be given to how best present this to the public in a way that makes it accessible and understandable. In the UK, the Dr Foster website provides large amounts of information on hospitals, but most of it is inaccessible for a consumer trying to choose between providers. The UK Healthcare Commission provides a much simpler presentation. It measures a small number of indicators on a four-point scale. This is more consumer-friendly because the measures are presented in a simple and understandable way, with some form of ranking. In the past, the Minister for Health and Ageing, Minister Roxon, has indicated that performance information is partly about consumer choice. If it is to enable consumers to choose, the information needs to be presented in a way that can be understood. To determine what will work best for Australian consumers, the government needs to test options on and with the public. However the information is presented, it will need to be accompanied by an awareness and information campaign, and we look forward to further work on that issue. In the meantime, the Greens will support this legislation on the understanding that we will have a debate on the amendments we are proposing, because we believe these amendments will significantly improve this legislation.