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INQUIRY INTO THE FUTURE SUSTAINABILITY OF HEALTH FUNDING IN THE ACT

S T A N D I N G C O M M I T T E E O N H E A L T H , A G E I N G A N D C O M M U N I T Y S E R V I C E S

D E C E M B E R 2 0 1 8

REPORT 5

I N Q U I R Y I N T O T H E F U T U R E S U S T A I N A B I L I T Y O F H E A L T H F U N D I N G I N T H E A C T

THE COMM ITTEE

COMMITTEE MEMBERSHIP

CURRENT MEMBERS

Ms Bec Cody MLA (Chair from 20 September 2018)

Mrs Vicki Dunne MLA (Member to 24 September 2018, Deputy Chair from 25 September 2018)

Ms Caroline Le Couteur MLA (Member)

PREVIOUS MEMBERS

Mr Chris Steel MLA (Chair to 24 August 2018)

Mr Michael Pettersson MLA (Member to 3 September 2018, Chair from 4 September 2018)

Mrs Elizabeth Kikkert MLA (Deputy Chair to 20 September 2018)

SECRETARIATMrs Josephine Moa (Secretary from July 2018)

Ms Kate Harkins (Secretary to June 2018)

Ms Lydia Chung (Administration Officer)

CONTACT INFORMATION

Telephone 02 6205 0136

Post GPO Box 1020, CANBERRA ACT 2601

Email [email protected]

Website www.parliament.act.gov.au

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http://www.parliament.act.gov.au/

mailto:[email protected]


RESOLUTION OF APPOINTMENT

At its meeting of 13 December 2016, the Legislative Assembly resolved to create:

A Standing Committee on Health, Ageing and Community Services to examine matters related to hospitals, community and public health, mental health, health promotion and disease prevention, disability matters, drug and substance misuse, targeted health programs and community services, including services for older persons and women, families, housing, poverty, and multicultural and indigenous affairs.1

TERMS OF REFERENCE

The Standing Committee on Health, Ageing and Community Services notes the following;

a) A feature of Australia’s health system is that both the Australian and State and Territory governments fund public hospitals with some private funding.

b) State and Territory Governments fund the majority of the hospital system in Australia at approximately a 50 per cent share.

c) The Australian Government funds a major share of private hospital costs, albeit indirectly through the private health insurance rebate, which is uncapped up to 35 per cent.

d) The ACT Government expenditure on health is $1.63 billion in 2017-18, or 31 per cent of the ACT Budget – the largest proportion of expenditure compared to any other output.

e) Australian Government support for public hospitals is now capped: it can grow no faster than 6.5 per cent each year.

f) The ACT has an ageing population and there is an increase in chronic disease and increasing complexity of disease and co-morbidity rates; and

g) Discussion has started between the Australian and State and Territory governments on new national health agreements.

The Committee resolves to inquire into and report on the future sustainability of health funding in the ACT, with particular reference to:

a) The efficiency of current health financing; particularly examining the alignment of funding with the purpose of the ACT’s health services, including the provision of quality and accessible health care to patients when they need it;

b) The nature of health funding and how it improves patient outcomes including innovative or alternative programs such as hospital in the home and walk in centres;

c) The sources and interaction of health financing in the ACT including:

i. ACT Government funding;

ii. Australian Government funding including Medicare;

1 Legislative Assembly for the ACT, Minutes of Proceedings, 13 December 2018, p. 13.

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iii. Private health insurance;

iv. Consumer out of pocket payments; and

v. Other sources.

d) The impact on health financing of:

i. Population growth and demographic transitions in the ACT and the surrounding region; and

ii. Technological advancements and health innovation.

e) The relationship between hospital financing and primary, secondary and community care, including the interface with the National Disability Insurance Scheme and residential aged care;

f) Funding the future capital needs of the health system in the ACT;

g) Relevant experiences and learnings from other jurisdictions, and

h) Any other relevant matter.

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ACRON YMS

Acronym Meaning

ABF Activity Based Funding

ABS Australian Bureau of Statistics

ACT Australian Capital Territory

ACTCOSS ACT Council of Social Services

ACT HealthACT Health DirectorateCanberra Health ServicesLocal Hospital Network

AIHW Australian Institute of Health and Welfare

AMA ACT Australian Medical Association ACT

CASP Community Assistance and Support Program

CHSP Commonwealth Home Support Program

Committee Standing Committee on Health, Ageing and Community Services

COTA Council of the Ageing

FTE full time equivalent

GP General Practitioners

GRACE Geriatric Rapid Acute Care Evaluation

HFE Health Funding Envelope

HIV Human Immunodeficiency Virus

IHPA Independent Hospital Pricing Authority

Inquiry Inquiry into the Future Sustainability of Health Funding in the ACT

Interim Agreement Addendum to the National Health Reform Agreement 2011

Legislative Assembly Legislative Assembly for the ACT

LGBTIQ Lesbian, Gay, Bisexual, Transgender, Intersex and Queer

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Minister Minister for Health and Wellbeing

National Health Reform Agreement

National Health Reform Agreement 2011

NDIS National Disability Insurance Scheme

NSW New South Wales

NT Northern Territory

Queensland Meeting Report Queensland Clinical Senate’s March 2016 Meeting Report

RoGS Productivity Commission’s annual Report on Government Services

WA Western Australia

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TABLE OF CONTENTS

T H E C O M M I T T E E ..............................................................................................................ICommittee Membership............................................................................................................................ i

Secretariat................................................................................................................................................ i

Contact Information.................................................................................................................................. i

Resolution of Appointment...................................................................................................................... ii

Terms of Reference.................................................................................................................................. ii

A C R O N Y M S .....................................................................................................................I V

R E C O M M E N D A T I O N S ..................................................................................................V I I I

1 I N T R O D U C T I O N ...........................................................................................................1Conduct of the Inquiry.............................................................................................................................. 1

Acknowledgements.................................................................................................................................. 2

2 S O U R C E S O F F U N D I N G ..............................................................................................3National Funding...................................................................................................................................... 3

ACT Funding............................................................................................................................................. 9

3 S U B M I S S I O N S ...........................................................................................................1 1Primary and Community Health Care...................................................................................................... 11

National Disability Insurance Scheme.....................................................................................................15

Aged Care............................................................................................................................................... 16

Information Technology and Digital Health.............................................................................................17

Approaches to Funding........................................................................................................................... 19

Contributors to Health Expenditure........................................................................................................ 21

4 A C T D E M O G R A P H I C ...............................................................................................2 4Population Growth................................................................................................................................. 24

Ageing Population.................................................................................................................................. 25

5 J U R I S D I C T I O N A L C O M P A R I S O N ............................................................................2 8Report on Government Services – Health................................................................................................28

Australian Institute of Health and Welfare..............................................................................................30

6 S T R A T E G I E S A D O P T E D I N O T H E R J U R I S D I C T I O N S ............................................3 4Queensland Clinical Senate – Value-Based Healthcare: Shifting from Volume to Value............................34

Western Australia Sustainable Health Review.........................................................................................36

7 C O N C L U S I O N ............................................................................................................3 8

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A P P E N D I X A – S U B M I S S I O N S ...................................................................................3 9

A P P E N D I X B – I N F O G R A P H I C R E F E R E N C E S ............................................................4 0

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RECO MMEND ATI ONS

R E C O M M E N D A T I O N 13.19 The Committee recommends that the ACT Government facilitate the AIDS Action Council in

providing mechanism for the Lesbian, Gay, Bisexual, Transgender, Intersex and Queer community to access practices that provide inclusive services.

R E C O M M E N D A T I O N 23.20 The Committee recommends that the ACT Government look into the benefits of increased funding

for preventative health interventions.

R E C O M M E N D A T I O N 33.33 The Committee recommends that the Commonwealth continue to fund the Commonwealth Home

Support Program. If the Commonwealth does cease payments through the Commonwealth Home Support Program, the Committee recommends that the ACT Government fund this program.

R E C O M M E N D A T I O N 43.39 The Committee recommends that the ACT Government investigate digital reform to provide a

strategy for improving communication between acute services, community based services, general practitioners and the patient and their carer.

R E C O M M E N D A T I O N 53.40 The Committee recommends that the ACT Government provide peer based HIV testing for gay and

bisexual men to help meet its goals and targets established in the National HIV Strategy.

R E C O M M E N D A T I O N 63.41 The Committee recommends that the ACT Government ensures the development of a territory

wide health strategy, which is made available to the Committee and the public as soon as possible.

R E C O M M E N D A T I O N 73.49 The Committee recommends that the ACT Government consider the adoption of patient-focused

service delivery, as patient-focused services encourage the development of more efficient models of care.

R E C O M M E N D A T I O N 83.50 The Committee recommends the ACT Government invest in a mandated minimum nurse/midwife-

to- patient ratio.

R E C O M M E N D A T I O N 95.17 The Committee recommends that, as the ACT has less than the national in average primary and

community health services providers, the ACT Government develop a workforce strategy to build on existing numbers.

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R E C O M M E N D A T I O N 1 05.33 The Committee recommends that the ACT Government investigate what the contributing factors

are that cause the highest costs to the Canberra Hospital, as well as Calvary Public Hospital.

5.34 The Committee further recommends that the ACT Government report back to the Legislative Assembly the cost analysis by the last sitting day of 2019.

R E C O M M E N D A T I O N 1 15.35 The Committee recommends that the ACT Government establish procedures and protocols to

ensure patients treated on time in emergency departments meet the national average benchmark.

R E C O M M E N D A T I O N 1 25.36 The Committee recommends that the ACT Government establish procedures and protocols to

ensure patients receive elective surgery in accordance with the national average benchmark

R E C O M M E N D A T I O N 1 36.13 The Committee recommends that the ACT Government, in conjunction with Health Care

Consumers Association, establish a forum to discuss value-based health care.

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SUSTAINABLE HEALTH REVIEW ACTBELOW IS A INFOGRAPHIC CREATED BY THE COMMITTEE BASED ON DATA ON

THE ACT PUBLIC HEALTH SYSTEM OVER THE LAST 10 YEARS

PopulationUp 22%

ED AttendancesUp 21%*

Hospital Admissions

Up 42%

Births (Public)Up 15%

$909 million infrastructure

investment

HEALTH COSTS CONTINUE TO RISE

Health spending in the last 10 years

$801M $1.39B

ACT public hospital visits per person cost 44% more than the

national average.*

THE SYSTEM IS UNDER PRESSURE

Growing population(up 70,000 persons in

the last 10 years)

Ageing Population (53% more people

over 65 in the last 10 years)

Chronic disease cost increasing

Fewest GPs per 100,000 persons in

Australia

KEY TO A SUSTAINABLE FUTURE FOR HEALTH

Patient first High Value Care Healthy lifestyles

Community Collaboration Digital Health

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1 INTRO DUCTIO N

1.1 The Standing Committee on Health, Ageing and Community Services (Committee) resolved to conduct an inquiry into the Future Sustainability of Health Funding in the Australian Capital Territory (ACT) (Inquiry) at its meeting of 21 November 2017.

1.2 In accordance with practice, the Committee commenced its Inquiry by informing the Legislative Assembly for the ACT (Legislative Assembly) of its resolution, and by publication of its terms of reference on 30 November 2017.

1.3 The Committee’s terms of reference set out in detail the matters the Committee proposed for inquiry. In addition to submissions received by the Committee, the Committee examined a number of publications including, but not limited to:

Grattan Institute – Controlling Costly Care: A Billion Dollar Hospital Opportunity;

Grattan Institute – Building Better Foundations for Primary Care;

Grattan Institute – Unlocking Skills in Hospitals: Better Jobs, More Care;

Australian Institute of Health and Welfare – Health Expenditure Australia 2015-16;

Productivity Commission – Report on Government Services 2017, Volume E: Health;

Queensland Clinical Senate – Value-Based Healthcare: Shifting from Volume to Value; and

Western Australia – Sustainable Health Review.

CONDUCT OF THE INQUIRY

1.4 Under its resolution of appointment, the Committee is empowered to examine matters which are the responsibility of the ACT Health Directorate and Canberra Health Services including but not limited to; hospitals, community and public health, mental health, health promotion and disease prevention, disability matters, drug and substance misuse, as well as targeted health programs. The Committee took up this Inquiry under that responsibility.

1.5 In accordance with established practice, the Committee advertised the Inquiry on the Legislative Assembly website and invited submission to be lodged with the Committee by Friday, 23 February 2018. During the Inquiry period, the Committee received 17 submissions from a number of organisations. A list of submissions received is provided at Appendix A.

1.6 The Committee also wrote to a number of organisations it considered likely to be interested in the Committee’s Inquiry, seeking views on the Inquiry. The Committee also invited the Minister for Health and Wellbeing (Minister) to make a submission on behalf of the ACT Government and those of its agencies involved in the area of administration and government activities related to the terms of reference.

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1.7 The Committee considered submissions received by the end of the period allowed for lodgement of submissions and, following consideration of submissions, allowed a further period to lodge submissions to the Inquiry.

1.8 As submissions for the Inquiry were received in early 2018 and research was conducted from early to mid-2018, to ensure consistency, the information presented in this report reflects data from the 2017-18 financial period. However, in some instances 2017-18 data was not available at the time of drafting this report. As such, in these situations, 2016-17 data was used.

1.9 After examining the information submitted to the Committee’s Inquiry, the Committee recognised that in addition to the ACT, a number of jurisdictions across the nation also identified that continuing trends in health care costs are unmaintainable.

1.10 The Committee also acknowledged that whilst submission appreciated the Committee taking an interest in the sustainability of health funding in the ACT, the need for a whole of government review was highlighted by a range of submissions.

1.11 With these two viewpoints in mind, the Committee resolved to present a report that highlighted the informative, relevant and valuable material submitted to the Committee’s Inquiry. In addition, the Committee decided to make a number of recommendations, which highlight strategies and processes the ACT Government could implement to reduce the costs associated to ACT health services.

1.12 The Committee notes that in the ACT, as across Australia, there’s an urgent need for government, health services and consumers to work together to identify how health care can be delivered differently. This focus will enable our health system to deliver better care and health outcomes, while using limited resource more effectively.

ACKNOWLEDGEMENTS

1.13 The Committee acknowledges the input received by individuals and organisations who provided submissions to the Committee’s Inquiry. The Committee also acknowledges the time and effort taken by those who provided submissions and would like to thank each submitter for their invaluable contributions to the Inquiry.

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2 SOURC ES OF FUNDIN G

2.1 ACT Health receives funding from several sources including Commonwealth funding under the National Health Reform Agreement 2011 (National Health Reform Agreement), various partnership agreements and appropriation funding through the ACT Government Budget.

2.2 Other funding sources include user charges and cross border revenue in relation to interstate (NSW mainly) patients and other minor, miscellaneous streams of income such as donations and patient revenue.

NATIONAL FUNDING

2.3 The Commonwealth funding to states and territories for public hospital services in 2017-18 was predominantly based on Activity Based Funding (ABF) with some elements of block funding.2

2.4 The National Health Reform Agreement and the National Health Reform Act 2011 gave rise to the national implementation of ABF from 1 July 2012 and the creation of statutory bodies such as the Independent Hospital Pricing Authority (IHPA), Administrator of the National Health Funding Pool and the National Health Funding Body.3

2.5 ABF is informed by the IHPA’s pricing model and pricing framework. ABF is intended to provide a transparent model of funding which reflects the level of patient activity and an efficient price for that activity.4

2.6 A key element of the IHPA’s pricing model is the National Efficient Price, which is a measure of the standardised national cost of efficient service provision for a unit of activity.5

2.7 The National Weighted Activity Unit is the measure of patient activity which reflects resource utilisation in the treatment of patients; the more complex the treated medical case, the greater the unit value (weighting). 6

2.8 In March 2017, the Commonwealth and states signed an addendum to the National Health Reform Agreement (Interim Agreement), effective from 1 July 2017 for three years. This Interim Agreement provides continued Commonwealth funding for public hospitals at a funding growth rate capped at 6.5 per cent per annum in aggregate (that is, nationally). The ACT and the Commonwealth also signed a separate bilateral agreement providing a

2 ACT Government, Submission 5, p. 10.3 ACT Government, Submission 5, p. 10.4 ACT Government, Submission 5, p. 10.5 ACT Government, Submission 5, p. 10.6 ACT Government, Submission 5, p. 10.

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guaranteed minimum Commonwealth financial contribution for ACT public hospital services for the period of the Interim Agreement.7

2.9 Under the Interim Agreement, the Commonwealth’s funding for each category of Activity Based Funding Service is calculated individually for each state by summing the previous year amount, the price adjustment and the volume adjustment. This calculation is done at the beginning of each financial year, and may then be revised based on actual levels of public hospital services as submitted to, and assessed by, the Administrator of the National Health Funding Pool, in a final reconciliation and payment process. An annual adjustment is conducted in arrears once actual volumes have been validated through a reconciliation process, it is designed to ensure the Commonwealth meets its agreed 45 per cent contribution to the funding of efficient growth under that Interim Agreement. 8

2.10 In 2017-18, National Health Reform funding was estimated to be $19.6 billion. This is an increase of $1.1 billion, or 6.0 per cent, from 2016-17. Table One shows the National Health Reform Funding provided to the ACT in 2017-18 and the estimated funding for 2018-19 and 2019-20.

Table One – National Health Reform Funding – Commonwealth Budget9

Hospital Services($ million)

Public Health ($ million)

Total($ million)

2017-18 368.2 6.3 374.5

2018-19 392.7 6.7 399.3

2019-20 418.8 7.0 425.8

2.11 Graph One shows, under the National Health Reform Agreement, the scope of public hospital services that are funded on an activity or block grant basis and are eligible for a Commonwealth funding contribution currently includes: all admitted and non-admitted services; all emergency department services provided by a recognised emergency department; and other outpatient, mental health, sub-acute services and other services that could reasonably be considered a public hospital service.10

7 ACT Government, Submission 5, p. 10.8 ACT Government, Submission 5, p. 11.9 2017-18 Commonwealth Budget, Budget Paper 3: Federal Financial Relations 2017-18, p. 15.10 ACT Government, Submission 5, p. 11.

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Graph One: Funding for Public Hospital Health Services11

2.12 Table Two identifies the amounts paid into each State Pool Account by the Commonwealth and the basis on which the payments were made, for the 2017-18 financial year.

Table Two: Funding by the Commonwealth into ACT State Pool Account 2017-1812

ComponentAmount paid by Commonwealth into ACT State Pool Account 2017-18

Activity Based Funding $353,445,000

Block Funding $25,677,000

Public Health Funding $6,459,000

ACT Total $385,581,000

2.13 Table Three identifies the amounts paid into each State Pool Account and State Managed Fund by the ACT and the basis on which the payments were made, for the 2017-18 financial year.

Table Three: Payments made by the ACT 2017-1813

Component Amount paid by the ACT 2017-18

State Pool Account - Activity Based Funding $583,900,000

11 Administrator of the National Health Funding Pool, National Health Reform funding flows, viewed 13 March 2018, <https://www.publichospitalfunding.gov.au/nationalhealth-reform/funding-flows>

12 Administrator of the National Health Funding Pool, 2017-18 Annual Report, October 2018, p. 232.13 Administrator of the National Health Funding Pool, 2017-18 Annual Report, October 2018, p. 232.

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https://www.publichospitalfunding.gov.au/nationalhealth-reform/funding-flows


Component Amount paid by the ACT 2017-18

State Managed Fund — Block Funding $45,847,000

ACT Total $629,747,000

2.14 Table Four identifies the amounts paid from each State Pool Account to Local Hospital Networks, a State Managed Fund or Other Organisations or Funds and the basis on which the payments were made, for the 2017-18 financial year.

Table Four: Payments from the ACT Pool Account 2017-1814

RecipientAmount paid from the ACT Pool Account 2017-18

ACT Local Hospital Network $1,013,545,000

State Managed Fund $25,677,000

Other Organisations or Funds $25,659,000

ACT Total $1,064,881,000

2.15 Table Five identifies the amounts paid from each State Managed Fund to Local Hospital Networks or Other Organisations or Funds and the basis on which the payments were made, for the 2017-18 financial year.

Table Five: Payments from the ACT State Managed Fund 2017-1815

RecipientAmount paid from the ACT State Managed Fund 2017-18

ACT Local Hospital Network $71,524,000

Other Organisations or Funds -

ACT Total $71,524,000

2.16 Table Six shows National Health Reform funding and payments by service category on a year-to-date basis for the ACT for June 2018. National Health Reform funding and payments are separated into the following service categories – activity-based funding, block funding, and other funding.

Table Six: National Health Reform Funding and Payments by Service Category16

14 Administrator of the National Health Funding Pool, 2017-18 Annual Report, October 2018, p. 234.15 Administrator of the National Health Funding Pool, 2017-18 Annual Report, October 2018, p. 234.16 Administrator of the National Health Funding Pool, Australian Capital Territory Report, June 2018, accessed 05 December

2018, <https://www.publichospitalfunding.gov.au/Reports/state?state=act&month=jun2018#table3>

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https://www.publichospitalfunding.gov.au/Reports/state?state=act&month=jun2018#table3


Service CategoryNational Health Reform Funding Year-to-Date ($)

National Health Reform Payments Year-to-Date ($)

Activity Based Funding

Acute admitted 594,774,199 656,574,319

Admitted mental Health 47,559,900 52,501,620

Sub-acute 55,547,760 61,319,460

Emergency Department 110,269,190 121,726,730

Non-admitted 109,993,747 121,422,667

Total Activity Based Funding 918,144,797 1,013,544,797

Block

Small rural hospitals 3,314,391 3,492,949

Teaching, training and research

25,873,172 31,008,848

Non-admitted mental health 42,336,068 37,021,834

Other non-admitted services 0 0

Total block 71,523,631 71,523,631

Other

Public health funding 6,459,298 6,459,298

Over deposit 0 0

Cross-border 114,600,000 19,200,000

Interest 0 0

Total other 121,059,298 25,659,298

Grand Total 1,110,727,726 1,110,727,726

2.17 Public hospitals also receive funding from other sources, including the Commonwealth, states and territories, and third parties for the provision of other specific functions and services outside the scope of the National Health Reform Agreement, for example, dental services, primary care, Home and Community Care, residential aged care and pharmaceuticals.17

2.18 A longer-term public hospital funding agreement between the Commonwealth and the states is proposed to commence on 1 July 2020. The draft public hospital funding agreement is currently being negotiated through Council of Australian Governments, with the current

17 ACT Government, Submission 5, p. 11.

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proposal being a continuation of the Interim Agreement terms for a further period of three years from 1 July 2020.18

2.19 The relative cost of hospital services in the respective State/Territory does not impact the funding received from the Commonwealth as it is based on National Efficient Price. Those jurisdictions who exceed the cap do so purely as a result of activity levels driven by underlying consumer demand.19

2.20 In addition to funding under the National Health Reform Agreement, the ACT Government also receives funding under various partnership agreements.

2.21 In 2017-18 the ACT received $0.2 million in funding under the National Partnership on the National Bowel Cancer Screening Program. This initiative funds the follow-up of participants who return positive test results and are not recorded as having attended a consultation with a health professional.20

2.22 In 2017-18 the ACT received $0.1 million in funding under the National Partnership on OzFoodNet. This initiative aims to develop a better understanding of the causes and incidence of foodborne disease in the community and build an evidence base for policy formulations.21

2.23 In 2017-18 the ACT received $2.4 million in funding under the National Partnership on Essential Vaccines. This National Partnership provides funding to the ACT for the purchase of essential vaccines that have not yet transitioned to centralised purchasing agreements.22

ACT FUNDING

2.24 ACT Health state that in the past five years, ACT Health’s total health expenses (not including capital) has increased from $1.29 billion to $1.61 billion, a growth of around $317 million or 5.6 per cent, per year.23

2.25 Since the 2015-16 Budget, the ACT Health Funding Envelope (HFE) growth rate has been budgeted at between four and six percent, with budgeted growth in 2017-18 currently being 5.69 per cent, which excludes items considered as ‘outside the HFE’ such as the expense costs of some major new policy and infrastructure investments.24

2.26 HFE is used to provide funding certainty for the Health Directorate, Canberra Health Services and the Local Hospital Network (collectively known as ACT Health) regardless of changes in Commonwealth funding contributions and other sources of income. The operating costs

18 ACT Government, Submission 5, p. 11.19 ACT Government, Submission 5, p. 11.20 2017-18 Commonwealth Budget, Budget Paper 3: Federal Financial Relations 2017-18, p. 19.21 2017-18 Commonwealth Budget, Budget Paper 3: Federal Financial Relations 2017-18, p. 19.22 2017-18 Commonwealth Budget, Budget Paper 3: Federal Financial Relations 2017-18, pp. 26-27.23 ACT Government, Submission 5, p. 4.24 ACT Government, Submission 5, pp. 12-13.

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associated with new capital initiatives are also funded from the HFE. The Envelope includes annual funding for price growth (indexation) and for growth in activity.25

2.27 In 2016-17, ACT Health received 11.8 per cent of its budget from non-ACT Government user charges and 2.4 per cent from other revenue sources such as, interest, gains and resources received free of charge including, for example, rebates from pharmaceutical companies.26

2.28 Capital funding decisions by Cabinet, such as those in relation to the current Infrastructure program, are outside the HFE arrangements. This is because the HFE is premised on providing budget certainty for overall net Controlled Recurrent Payments as expenses (less depreciation) rather than for capital funding.27

2.29 The current HFE arrangements provide a degree of Budget certainty for ACT Health, regardless of the funding changes from the Commonwealth, and as such, provide the basis for long-term planning and investment decisions, with the ACT Government able to readily adjust the year on year budget as needed, on the basis of advice from those delivering our health services, and in response to local needs, latest forecasts and plans. However, funding changes from the Commonwealth, notably cuts that occurred in the 2014-15 Commonwealth Budget result in state/territory governments making up any shortfall.28

2.30 Funding provided in the 2017-18 ACT Budget, to ACT Health, under HFE included:

Expansion of Hospital in the Home ($136,000);

Initiatives and innovation in preventative health ($4 million over four years);

Funding provided to Health Care Consumers Association to develop a framework for patient care navigators ($100,000);

More mobile dental Clinics ($2.5 million over four years);

More nurses in Canberra ($36 million over for years);

Establishment of an Office for Mental Health ($2.9 million over four years);

ACT Pathology Laboratory Information System study ($1.4 million);

Scoping study for expanded Northside hospital facilities ($3.3 million over two years);

Rehabilitation beds for Dhulwa Mental Health Unit ($13.8 million over four years);

Suicide prevention support services ($1.8 million over four years);

Support for bulk billing General Practitioners (GPs) ($1 million over three years);

Supporting mental health for vulnerable Canberrans ($5.4 million over four years);

University of Canberra Public Hospital operational readiness ($15.8 million over two years);

Whooping cough vaccinations for pregnant mums ($732,00 over four years); and

25 2017-18 ACT Budget, Budget Paper 3: Expense Initiatives, June 2017, p. 102.26 ACT Government, Submission 5, p. 13.27 ACT Government, Submission 5, p. 13.28 ACT Government, Submission 5, p. 13.

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Year seven health checks ($2.7 million over four years).29

2.31 Funding provided in the 2017-18 ACT Budget, to ACT Health, under infrastructure and capital initiatives included:

Expansion of the Centenary Hospital for Women and Children ($68.1 million over four years);

Improved infrastructure for acute aged care and cancer inpatients ($17.4 million over two years);

Upgrade works to a range of ACT Health facilities ($844,00);

More nurse-led walk-in centres ($9.1 million);

Replacement of the ACT Notifiable Diseases Database ($398,000);

New health centre for Aboriginal and Torres Strait Islander Canberrans ($120,00);

Surgical Procedures, Interventional Radiology and Emergency Centre in Canberra Hospital (6.0 million); and

Establishment of a new clinical school for nursing, midwifery and allied health staff in conjunction with the Faculty of Health at the University of Canberra ($1.1 million).30

29 2017-18 ACT Budget, Budget Paper 3: Expense Initiatives, June 2017, pp. 102-106.30 2017-18 ACT Budget, Budget Paper 3: Infrastructure and Capital Initiatives, June 2017, pp. 144-146.

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3 SUBMI SS IO NS

3.1 The Committee called for submissions on 30 November 2017. In January, the Committee resolved to extend the submission closing dated from 1 February to 23 February 2018. The Committee permitted an extension to the Commonwealth Department of Health to 9 March 2018, however, the Committee did not end up receiving a submission from the Commonwealth Department of Health.

3.2 The Committee received 17 submission in total, 15 of which were from peak representative bodies and organisations. The ACT Government also provided a submission to the Committee’s Inquiry. One submission was not published by the Committee.

3.3 On 11 September 2018, the Committee resolved to table a report that reflected the evidence provided within the submissions. The Committee also considered evidence presented by other jurisdictions, academic literature, as well as evidence provided in government reports including the Productivity Commission, the Australian Institute of Health and Welfare (AIHW), the Australian Bureau of Statistics (ABS) and ACT Health.

3.4 Below is a summary of some of the key points presented in the submissions received by the 15 peak representative bodies and organisations, as well as the submission received by the ACT Government. This summary is not meant to be exhaustive and the Committee urges readers of this report to also consider reading the submissions separately. For more details on the submission provided please see the Legislative Assembly website and Appendix A.

PRIMARY AND COMMUNITY HEALTH CARE

3.5 The AIDS Action Council of the ACT, the leading community-based Human Immunodeficiency Virus (HIV) organisation, emphasised the importance in investing in primary health care systems as a method for reducing excessive hospital and specialist care costs. For example, primary prevention efforts have dramatically reduced tobacco use and subsequent morbidity, mortality and health care costs.31

3.6 The AIDS Action Council of the ACT also highlighted that there does not appear to be a simple way for an individual to identify if a primary health service provides Lesbian, Gay, Bisexual, Transgender, Intersex and Queer (LGBTIQ) inclusive services. Such limitations act as a barrier for LGBTIQ individuals accessing services early. Consequently, LGBTIQ individuals who access the public health system are more likely to do so when sicker, which subsequently increases health care costs. Better access for and earlier access to appropriate services by the LGBTIQ community would reduce long run costs.32

31 AIDS Action Council of the ACT, Submission 9, pp. 1-2.32 AIDS Action Council of the ACT, Submission 9, pp. 2-3.

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3.7 The Australian Breastfeeding Association’s, Australia’s largest breastfeeding information and support service, submission highlighted the importance of the Baby Friendly Health Initiative in having a positive impact on breastfeeding outcomes. The inclusion of this initiative in ACT hospitals would positively impact breastfeeding outcomes, which would result in increased positive health outcomes of babies.33

3.8 The Australian Breastfeeding Association submission also noted the potential for reduced stress on the health system through the adoption of the Baby Friendly Health Initiative. The continued breastfeeding up to six months of age was identified as a contributor to lower infections, morbidity and mortalities, fewer dental malocclusions, as well as protection against overweight and diabetes later in life.34

3.9 In addition to primary targeted health care initiatives, a number of submissions also discussed the role of allied health professionals in both the acute care space and in the community health sphere. The Australian Physiotherapy Association, a peak body representing the interests of Australian physiotherapists and their patients, highlighted the role that physiotherapists are currently playing in the acute space and identified the community sphere as needing greater development, particularly relating to the management of chronic illness.35

3.10 Nurse-led walk-in centres were also identified as an area that has utilised allied health professionals in both the acute care space, and in the community health sphere. The Australian Nursing and Midwifery Federation ACT Branch, which represents the industrial, professional and social justice interests of the majority of the Nursing and Midwifery workforce in the ACT, highlighted their support for nurse-led walk-in centres. 36

3.11 The Australian Salaried Medical Officers Federation, the Australian trade union representing salaried doctors, noted that they had no formal position on nurse-led walk-in centres. However, they did argue that there is little evidence which supports the perception that too many patients attend the Emergency Department for minor problems that would be better managed elsewhere, and that these patients impair the ability of the Emergency Department to attend to more urgent patients. Despite the lack of evidence supporting this notion ACT Health continues to foster these perceptions.37

33 Australian Breastfeeding Association, Submission 6, pp. 7-10.34 Australian Breastfeeding Association, Submission 6, p. 2.35 Australian Physiotherapy Association, Submission 2, pp. 1-17.36 Australian Nursing and Midwifery Foundation, Submission 11, p. 7.37 Australian Salaried Medical Officers Federation, Submission 16, p. 11.

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3.12 The Australian Institute of Health and Welfare estimated that over 8,100 (or 6 per cent) of all hospital admissions in the ACT in 2015-2016 could have been avoided if ACT residents had accessed preventative health interventions from the primary and community health sectors beforehand. Greater intervention by the ACT Government into the primary health care system, including through the expansion of nurse-led walk-in-centres was identified as an initiative that would improve coordination between services, while reducing costs for necessary hospitalisations.38

3.13 The Australian Medical Association ACT (AMA ACT), the principal representative body for medical practitioners in the ACT, also raised concerns with the cost and resources associated to the functioning of nurse-led walk-in centres. Specifically, AMA ACT noted the $9 million per year recurrent cost for the Belconnen and Tuggeranong nurse-led walk-in centres. AMA ACT questioned what type of general practice incentives could have been put in place to deal with similar presentations in a more cost effective method with a total of $54 million available since the inception of current nurse-led walk-in centres.39

3.14 With specific regards to the utilisation of GPs in providing a preventive health focus and strengthened community care approaches, ACT Health data shows that increasing access to bulk billed GPs remains a problem area. The ACT Government submission stated that the ACT still has one of the lowest rates of full time equivalent (FTE) GPs in the country, with 68.6 GPs per 100,000 people compared to an Australian average of 93.1. The ACT has a bulk-billing rate significantly below the Australian average with 58.1 per cent of non-referred attendances being bulk billed compared to an Australian average of 84.6 per cent. In addition, 9.7 per cent of people in the ACT reported deferring access to GP’s due to cost compared to a national average of 5 per cent.40

3.15 The Committee notes that in the 2017-18 Budget the ACT Government provided $1.05 million over three years ($350,000 per year) as an incentive for general practice groups to provide more bulk billed health care, including bulk billed allied health care services.

3.16 The Committee further notes that in the 2017-18 Budget the ACT Government provided $9.3 million in recurrent funding and $3.4 million in capital funding to establish a nurse-led walk-in centre for the Gungahlin community, commence planning for a nurse-led walk-in centres in the Weston Creek region, and undertake scoping work for a nurse-led walk-in centre in the Inner North.

38 Australian Nursing and Midwifery Foundation, Submission 11, p. 7.39 Australian Medical Association ACT, Submission 17, pp. 5-6.40 ACT Government, Submission 5, p. 9.

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3.17 Table One identifies the recurrent and capital funding for nurse-led walk-in centre funding over a four year period.

Table Seven: Nurse-Led Walk-In Centre Funding41

2017-18$’000

2018-19$’000

2019-20$’000

2020-21$’000

Total$’000

Capital 3,425 0 0 0 3,425

Depreciation 0 86 86 86 258

Associated Expense

428 2,748 2,907 2,995 9,078

Net Expense 428 2,834 2,993 3,081 9,336

3.18 In addition to nurse-led walk-in centres, in the 2017-18 Budget the ACT Government provided $36 million in recurrent funding to employ more graduates and nurse navigators to help patients better understand access to services available through the health system. This funding will also provide for an increase to the Nursing and Midwifery Scholarship fund.

Table Eight: More Nurses in Canberra42

2017-18$’000

2018-19$’000

2019-20$’000

2020-21$’000

Total$’000

Expenses 4,492 7,977 10,894 12,638 36,001

Offset – Expenses

-4.492 -7.977 -10.894 -12.638 -36,001

Net Expenses 0 0 0 0 0

Recommendation 13.19 The Committee recommends that the ACT Government facilitate the AIDS Action Council in

providing mechanism for the Lesbian, Gay, Bisexual, Transgender, Intersex and Queer community to access practices that provide inclusive services.

41 2017-18 ACT Budget, Budget Paper 3: Expense Initiatives, June 2017, p. 145.42 2017-18 ACT Budget, Budget Paper 3: Expense Initiatives, June 2017, p. 103.

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Recommendation 23.20 The Committee recommends that the ACT Government look into the benefits of increased

funding for preventative health interventions.

NATIONAL D ISABILITY INSURANCE SCHEME

3.21 The interface between ACT Health and community care services was highlighted in a number of submissions. Specific reference to the interface between ACT Health and the National Disability Insurance Scheme (NDIS) was identified.

3.22 Specifically, the capacity of the Community Assistance and Support Program (CASP), as a result of the implementation of the NDIS, was raised. Submissions highlighted concern with the initial scope of CASP to fill gaps in service delivery for individuals who were transitioning to the NDIS or individuals who were not eligible for the NDIS. It was noted that the funding provided for CASP does not consider the programs scope or capacity to assist with gaps created as a result of the implementation of the NDIS.43

3.23 The ACT Council of Social Services (ACTCOSS), the peak representative body for people living with low incomes or disadvantages, and not-for profit organisations in the ACT, also discussed CASP in their submission. ACTCOSS had also recognised that CASP had become a gap filler, which emerged as a result of multiple national reforms.44

3.24 In Addition to CASP, the 12 week post hospital Transitional Support Program provided by Community Options was identified as a program that is functioning beyond its capacity. Specifically, Community Options, a not-for-profit provider of aged care, disability and community support, advised the Committee that due to NDIS delays with transitioning the participant from the hospital to the home, they have had to provide significantly higher levels of support for longer periods of time within the current funding scope of the program. Community Options went on to advise that one particular case resulted in Community Options providing support to an individual for 12 months, nine months beyond the Transitional Support Program timeframe.45

3.25 ACTCOSS also informed the Committee that the trend in delays to the transition of individuals to the NDIS, as well as the 12 week timeframe of the Transitional Support Program is insufficient. As a result of these delays, individuals are referred to CASP as they wait to be accepted into the NDIS. ACTCOSS highlighted that the Community Options’ CASP had 150 clients that had been referred to the NDIS in the last six months of 2017, with only five clients successfully transitioned in that period.46

43 Community Options, Submission 10, p. 9.44 ACT Council of Social Services, Submission 12, p. 3. 45 Community Options, Submission 10, p. 9.46 ACT Council of Social Services, Submission 12, p. 4.

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AGED CARE

3.26 Aged care was another community care service that was identified in submissions, which examined the interface between ACT Health and aged care. Communication and coordination between the acute space and aged care facilities was expressed as requiring a more formal structure by the Council of the Ageing (COTA), a peak organisation in the ACT concerned with all issues relating to ageing. Specifically, COTA supported efforts to improve health care for residents in the Territory’s aged care facilities. The Geriatric Rapid Acute Care Evaluation (GRACE) program was identified as a potential model that promotes collaboration and coordination between a resident’s GP, aged care facility staff and Calvary Public Hospital.47

3.27 The utilisation of the GRACE program was further identified by the Health Care Consumers Association, a health promotion agency and peak consumer advocacy organisation in the Canberra region. The Health Care Consumers Association recognised that GRACE provides hospital-to-home services that improves the continuity of care to residents of aged care facilities. It was noted that this model is promising as it seeks to reduce avoidable hospital admission, as well as encouraging collaborative care between aged care facility staff, GPs and hospital staff.48

3.28 Additionally, the Capital Health Network, the Territory’s primary health network supporting general practice, primary, aged care and community care services, recognised that GRACE services do demonstrate early success with a number of residents of aged care facilities diverted from the Emergency Department and appropriate community based interventions provided to address health and care needs.49

3.29 However, beyond the GRACE program, barriers created by the recent national aged care system reforms and the introduction of new access pathways to aged care services under the Commonwealth Government’s My Aged Care, which provides access to aged care and information services, was identified by Community Options. In particular, it was highlighted that these initiatives have made it increasingly hard for Community Options to respond to referrals from hospitals through their Commonwealth Home Support Program (CHSP). Reduced service availability through CHSP creates obstacles for discharge thus increasing hospitalisation days of older ACT residents for non-medical reasons and largely due to lack of services available in the community.50

3.30 The Committee was informed that from 1 July 2020, with the planned implementation of the second stage of national aged care reforms, CHSP funding will no longer be available. As such, there will be no capacity to respond to referrals from ACT hospitals for in-home and community based services following older ACT residents’ discharge from hospital. On the basis of the historical service delivery data analysis, Community Options projected that the gap in

47 Council of the Ageing, Submission 4, pp. 1-6.48 Health Care Consumers Association, Submission 3, pp. 30-31.49 Capital Health Network, Submission 8, p. 750 Community Options, Submission 10, p. 7.

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service availability will be approximately 1,000 older ACT residents not being able to access in-home support services following discharge from hospital after 1 July 2020. As a result of the cessation of CHSP funding, Community Options projected an increase in the cost to ACT Health system in excess of $7.8 million.51

3.31 It is also noteworthy that the total annual expenditure for Community Options’ post hospital service delivery to older ACT residents through CHSP is $1.4 million. As such, the net saving to the ACT Health system, should these services continue to be funded by the ACT Government post 1 July 2020, would be $6.4 million.52

3.32 The Committee notes that if CHSP ceases funding from similar services could be sourced from other programs and arrangements. However, the Committee is concerned that there may not be sufficient funding from alternate programs or arrangements that will support ACT residents who are currently participating in the CHSP.

Recommendation 33.33 The Committee recommends that the Commonwealth continue to fund the

Commonwealth Home Support Program. If the Commonwealth does cease payments through the Commonwealth Home Support Program, the Committee recommends that the ACT Government fund this program.

INFORMATION TECHNOLOGY AND D IGITAL HEALTH

3.34 The utilisation of telehealth was highlighted in a number of submissions as an alternative mode of patient management, which would reduce the burden on acute services and improve patient experience. The Australian Physiotherapy Association noted that telehealth has the opportunity to reduce the burden on patients and transport facilities by offering alternative options for health delivery. Additionally, outpatient departments within organisations would be under less pressure, reducing the wait times for patients.53

3.35 Coordination of services was also identified as reducing the burden on acute services through telehealth and digital health strategies. For example, if a patient with multiple co-morbidities required three outpatient appointments, the appointments could be combined or happen on the same day. Additionally, if a patient required a number of procedures under general anaesthesia, these procedures could happen under one general anaesthetic or one visit to the hospital. The utilisation of telehealth and digital consultation would provide an avenue where these examples could be achieved, as well as providing patients with improved service coordination.54

51 Community Options, Submission 10, p. 8.52 Community Options, Submission 10, pp. 8-9.53 Australian Physiotherapy Association, Submission 2, p. 8.54 Health Care Consumers Association, Submission 3, pp. 1-48.

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3.36 The Capital Health Network’s submission directed the Committee to the ACT health specific Needs Assessment it produced in 2016. The Needs Assessment highlighted the dependency relationship between the management of chronic conditions, transitions in care and the need for digital reform to enhance communication. The Needs Assessment further highlighted that if transitions in care are not managed appropriately, then the ongoing management of conditions are weaker, which in turn create adverse outcomes for both the person who is ill and the system that is forced to respond to greater needs as a result. The crucial link is communication between acute services, community based services, GPs, the patient and their carers. The need for digital reform was identified as a strategy for improving such communication.55

3.37 Technological advancements were also identified by the AIDS Action Council of the ACT, in increasing the frequency of testing gay and bisexual men. At present there are a number of new testing options available including home based screening, rapid point of care screening in community settings and dried blood spot HIV screening. Peer based testing was specifically identified as an approach which provides an opportunity to reach gay and bisexual men who would otherwise not have tested. This approach would also assist the ACT in meeting the goals and targets established in the National HIV Strategy.56

3.38 A number of submissions57 also recognised the need for a territory-wide digital health strategy. ACT Health reminded the Committee that it is developing a Territory-wide Health Services Framework, which provides the strategic framework for the planning and delivery of territory-wide health services over the next decade. The reform objectives include improving access to services, increasing efficiency and freeing up hospital capacity through contemporary service delivery solutions and models of care. The submission also confirmed the development of a Digital Health Strategy 2018-2028, which provides a plan for ACT Health to build the digital health capabilities necessary to support a sustainable, innovative and world-class health system for the ACT. The Digital Health Strategy aims to establish overarching principles to guide the design and development of digital health capabilities to support the delivery of person-centred, safe and effective care. The Committee notes that at the time drafting this report the strategy was not available on the ACT Health Website.

Recommendation 43.39 The Committee recommends that the ACT Government investigate digital reform to

provide a strategy for improving communication between acute services, community based services, general practitioners and the patient and their carer.

Recommendation 555 Capital Health Network, Submission 8, p. 1.56 AIDS Action Council of the ACT, Submission 9, pp. 3-4.57 Health Consumers Association, Submission 03.

Capital Health Network, Submission 08.

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3.40 The Committee recommends that the ACT Government provide peer based HIV testing for gay and bisexual men to help meet its goals and targets established in the National HIV Strategy.

Recommendation 6

3.41 The Committee recommends that the ACT Government ensures the development of a territory wide health strategy, which is made available to the Committee and the public as soon as possible.

APPROACHES TO FUNDING

3.42 Different models of funding, and shortfalls in the current funding model, were highlighted throughout submissions. The Health Care Consumers Association suggested that funding penalties for avoidable complications encourages under reporting and grows a risk adverse approach whilst funding arrangements should reward hospitals for strong performance rather than penalise underperformance.58

3.43 Co-operatives Commons and Communities Canberra, an unincorporated community group that recently emerged from SEE-Change ACT, recommended the consideration of an alternative borrowing framework. This alternative borrowing framework would enable the community to voluntarily contribute to ACT health services, in return for a fixed annual discount on their tax, for a fixed period. The ACT Government would avoid the cost of renting the capital (borrowing) from traditional interest bearing sources, thereby reducing their expenses. The ACT taxpayers who provide the money would get a return on their prepayment via an annual discount on taxes payable, over a fixed period. For example, this could be a six per cent annual tax discount for 15 years. The interest bearing option requires taxpayers to pay significantly more money than a project is worth, while the taxpayer prepayment and discount option provides the twin benefits of less money required for a project, and a reduced tax burden for the individual taxpayers involved in the plan.59

3.44 Currently, many areas of the ACT public health care system rely upon the Nursing Hours per Patient Day workload management tool. The Nursing Hours per Patient Day tool was highlighted as an outdated tool as it no longer reflects the acuity of patients on wards, changes to work practices, as well as models of care and care environments. Additionally, the utilisation of this tool does not allow nurses and midwives to proactively manage workloads in real-time. As such the Australian Nursing and Midwifery Foundation recommended that the ACT Government invest in a Mandated Minimum Nurse/Midwife-to-Patient Ratios Framework instead. This Framework would improve patient outcomes, reduce nursing staff turnover and

58 Health Care Consumers Association, Submission 3, p. 14.59 Co-operatives, Commons and Community Canberra, Submission 7, pp. 1-2.

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decrease wait times. Such improvements would result in savings related to the costs associated to staff turnover and Hospital Acquired Complication.60

3.45 The Public Health Association of Australia, the principal non-government organisation for public health in Australia, argued that the financial outflows on preventative health care, or the maintenance of wellness, have the character of investments. Whereas, outflows on the redress of illness have the character of expenses. Therefore, successful health investments make possible future health gains, or limit future health costs. By contrast, expenses made on illness or injuries are simply resources disposed of, which does not always generate future gains.61

3.46 Delays in accessing either elective or emergency treatment were also identified as a contributor to increased risk of morbidity and mortality. Changes so that resources are focussed on patients’ needs rather than statistical targets were recommended. The current funding model does not encourage patient-focused service delivery. Keeping patients at the centre of funding decisions will encourage development of more efficient models of care. Giving hospital service units more autonomy will allow them to be more responsive to changes in health care requirements, and to engineer efficiencies more quickly and effectively.62

3.47 A patient-focused service delivery and a move to high-value health care was identified as a priority in a number of submissions. High-value health care is defined as a value based health care system that aims to improve lower health costs and focuses on the interventions and outcomes that patient’s value, thereby ensuring limited resources are directed toward high-value interventions.63

3.48 This definition of high-value health care works in conjunction with a program called Choosing Wisely, which focuses on only having tests and procedures that are determined as required, rather than a standard process. This also links in with findings in the Queensland Clinical Senate, which is discussed in Chapter Six: Strategies Adopted in other Jurisdictions.64

Recommendation 7

3.49 The Committee recommends that the ACT Government consider the adoption of patient-focused service delivery, as patient-focused services encourage the development of more efficient models of care.

Recommendation 8

60 Australian Nursing and Midwifery Foundation, Submission 11, p. 6.61 Public Health Association, Submission 13, p. 5.62 Royal Australasian College of Surgeons, Submission 14, p. 3.63 Health Care Consumers Associations, Submission 3, p. 15.64 Health Care Consumers Associations, Submission 3, p. 17.

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3.50 The Committee recommends the ACT Government invest in a mandated minimum nurse/midwife-to- patient ratio.

CONTRIBUTORS TO HEALTH EXPENDITURE

3.51 The University of Canberra Health Research Institute highlighted that the annual average growth of Government funded admitted patient expenditure was 7.8 per cent, which is higher than the average growth for all government expenditure of 7.0 per cent per year. It is also higher than Education which grew at 6.9 per cent per year and higher than public order and safety which grew at 7.0 per cent per year.65

3.52 The ACT Government highlighted that the ‘management of an ageing population, the increases in prevalence of chronic disease and significant and ongoing co-morbidities challenge the existing system and its associated funding models’.66

3.53 However, the Canberra Health Research Institute argued that ‘There are indeed good arguments for a high rate of health expenditure growth in the areas which produce significant improvements in health outcomes. But the arguments that ageing, increasing chronic disease rates and high health price increases are the main reason we need high rates of health expenditure growth are misplaced’.67

3.54 In addition to the ageing population and increased chronic disease, ACT Health noted that they currently provide services for a catchment of approximately 400,000 people in the ACT and a further 200,000 people from the surrounding Southern New South Wales (NSW) area. Furthermore, 14 per cent of all Emergency Department presentations at Canberra Hospital are NSW residents and a significant number of these patients are high acuity/critical referrals. NSW residents represent 30 to 35 per cent of all admissions to Canberra Hospital. Further population growth in the Southern NSW region provides a significant challenge to the management of the ACT health care system68

3.55 Contrary to ACT Health reasoning, the Health Research Institute identified the main driver of the increase in admitted patient expenditure was the increase in the real volume of admitted patient services per person, which grew 2.8 per cent. This is not the real volume of services per person treated in hospital, but is per person in the general population. This real volume of services per person factor accounts for 53 per cent of the increase in expenditure.69

3.56 Possible arguments for the 2.8 per cent per year increase associated to the real volume of services include expenditure that deals with under treatment of a disease in the past. For

65 Canberra University Health Research Institute, Submission 15, p. 2.66 ACT Government, Submission 5, p. 7.67 Canberra University Health Research Institute, Submission 15, p. 3.68 ACT Government, Submission 5, p. 5.69 Canberra University Health Research Institute, Submission 15, p. 8.

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example, under treatment of diabetes because it hasn’t been diagnosed; expenditure that improves the quality of the outcome arising from the treatment; and expenditure for a disease where there had been a shift from outpatient to inpatient treatment. However, if the above arguments do not apply, the Health Research Institutes maintains that the 2.8 per cent per year increase in the real volume of admitted patient services per person has been a wasteful allocation of resources.

3.57 The Health Research Institute proposed that funding system be changed, so that in setting the budget for the coming year for each admitted patient cost centre, that budget holders for each cost centre first receive a base level increase in funding of about 4.7 per cent per year to account for expected general inflation increases (2.0 per cent), excess health price inflation (0.5 per cent), ageing (0.5 per cent) and population growth (1.7 per cent). Anything above this base level increase in funding should be justified as New Policy Proposals which demonstrates the extra health and/or cost savings that would be achieved by the proposed expenditure.70

3.58 The Committee notes that the ACT Government submission highlights ageing population as a contributing factor to rising health expenditure. The Committee further notes that statistics from the ABS reflects ACT ageing population as only increasing 0.5 years over the past 10 years. Additionally, the Committee notes that the median age in the ACT is younger the National average.

3.59 However, the Committee does acknowledge that the number of Australians turning 65 years of age is projected to increase more rapidly over the next decades, as further cohorts of baby boomers (those born between the years 1946 and 1964) turn 65. Further examination of ACT’s population growth and ageing population in Chapter Four: ACT Demographic .

70 Canberra University Health Research Institute, Submission 15, p. 14.

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4 ACT DEMO GRAP HIC

4.1 A number of submissions identified population growth and ageing population as pressure points in the health system. There is a range of views on the cost impact of both factors. As such, the Committee was interested in identifying ACT rates of growth and changing demographic.

POPULATION GROWTH

4.2 The ABS reports that the Australian population was 24.9 million at the end of the March 2018 quarter. This is a growth of 381,000 (1.6 per cent) between 2017 and 2018.71 The Australian population has also seen considerable change over the past 10 years. Between March 2008 and March 2018, the Australian population has increased 16.9 per cent, from 21.3 million to 24.9 million.72

4.3 Of the 24.9 million people living in Australia, 420,000 reside within the ACT. This is a growth of 8,500 (1.6 per cent) between 2017 and 2018.73 The ACT population increased from 342,700 in March 2008 to 419,200 in March 2018. This is an increase of 23.3 per cent, which is higher than the Australian population growth over the past 10 years.74

4.4 In 2013, the ABS provided three population growth projections for the period 2012 to 2061 for each state and territory. Graph Two highlights the three population growth projections. Series B of the population projections largely reflects current trends in fertility, life expectancy at birth and net overseas migration. Whereas series A and C of the population projections are based on high and low assumptions for each of these variables respectively.75

4.5 Series A projects the largest population for the ACT, increasing from 375,100 people at 30 June 2012 to 904,100 in 2061. Series B projects an increase to 740,900 people in 2061, while the smallest population of the three main series is projected in Series C (612,400).76

71 Australian Bureau of Statistics, Australian Demographic Statistics, March 2018, Australian Demographic Statistics Data Cube: Excel Spreadsheet, cat. No. 3101.0, viewed 02 October 2018, <http://www.abs.gov.au/ausstats/[email protected]/mf/3101.0>

72 Australian Bureau of Statistics, Australian Demographic Statistics, March 2008, Australian Capital Territory, cat. No. 3101.0, viewed 02 October 2018, <http://www.abs.gov.au/AUSSTATS/[email protected]/0/A9AAEFB8D2C053D6CA2575120010348E?opendocument>

73 Australian Bureau of Statistics, Australian Demographic Statistics, March 2018, Australian Demographic Statistics Data Cube: Excel Spreadsheet, cat. No. 3101.0, viewed 02 October 2018.

74 Australian Bureau of Statistics, Australian Demographic Statistics, March 2008, Australian Capital Territory, cat. No. 3101.0, viewed 02 October 2018.

75 Australian Bureau of Statistics, Population Projections, Australia, 2012 (base) to 2101, Main Features, cat. No. 3222.0, viewed 13 March 2018, <http://www.abs.gov.au/ausstats/[email protected]/mf/3222.0>

76 Australian Bureau of Statistics, Population Projections, Australia, 2012 (base) to 2101, Australian Capital Territory, cat. No. 3222.0, viewed 13 March 2018.

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http://www.abs.gov.au/ausstats/[email protected]/mf/3222.0



Graph Two: ACT Projected Population Growth.77

4.6 The Committee notes that these projections are not predictions or forecasts, but simply illustrations of the growth and change in population, which were made based on certain assumptions about future levels of mortality, internal migration and overseas migration.

AGEING POPULATION

4.7 The median age of the ACT population has not seen considerable change over the past 10 years. Between June 2007 and June 2017 the median age has slightly increased from 34.5 years to 35 years. This is younger than the Australian median age of 37.3 years and the second youngest of all states and territories, after Northern Territory (NT) (32.7 years).78

4.8 In 2007, the ACT population aged between zero and 14 years was 18.6 per cent, which was less than the Australian proportion of 19.4 per cent.79 In the 10 years between 2007 and 2017, the proportion of children aged between zero and 14 years increased from 18.6 per cent to

77 Australian Bureau of Statistics, Population Projections, Australia, 2012 (base) to 2101, Australian Capital Territory, cat. No. 3222.0, viewed 13 March 2018.

78 Australian Bureau of Statistics, Regional Population by Age and Sex, Australia, 2017, cat. No. 3235.0, viewed 02 October 2018, < http://www.abs.gov.au/ausstats/[email protected]/mf/3235.0>

79 Australian Bureau of Statistics, Population by Age and Sex, Regions of Australia, 2007, Australian Capital Territory, cat. No. 3235.0, viewed 09 March 2018, <http://www.abs.gov.au/ausstats/[email protected]/Products/3235.0~2007~Main+Features~Australian+Capital+Territory?OpenDocument>

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http://www.abs.gov.au/ausstats/[email protected]/Products/3235.0~2007~Main+Features~Australian+Capital+Territory?OpenDocument

http://www.abs.gov.au/ausstats/[email protected]/Products/3235.0~2007~Main+Features~Australian+Capital+Territory?OpenDocument



19.1 per cent of total population. At the end of 30 June 2017, the ACT recorded the largest percentage increase in the number of children aged zero to 14 years (2.6 per cent). Additionally, the number of children aged zero to 14 years in the ACT (19.1 per cent) was higher than the Australian proportion (18.9 per cent).80

4.9 At 30 June 2007, the proportion of the ACT population aged between 15 and 64 years was 71.6 per cent. In comparison, the proportion of 15 to 64 year olds in the Australian population was 67.4 per cent.81 At 30 June 2017, both the ACT and the Australian population aged between 15 and 64 years reflected a decrease from the 2007 statistics. The ACT population aged between 15 and 64 years was 68.5 per cent, a decrease of 3.2 per cent. In comparison the proportion of 15 to 64 year olds in the Australian population was 65.7 per cent, a decrease of 1.7 per cent.82

4.10 Over the 10 years between 2007 and 2017, the proportion of the ACT population aged 65 years and over increased from 9.8 per cent to 12.5 per cent.83 The ABS forecasts that this age group across Australia is projected to increase more rapidly over the next decades, as further cohorts of baby boomers (those born between the years 1946 and 1964) turn 65.84

4.11 The Committee notes that of the estimated 3.5 million older Australians aged 65 years and over, 50.7 per cent had a disability. Of these older Australians living with disability, the proportion that reported a profound or severe limitation was 36.4 per cent in 2015. The proportion with a moderate limitation was 14.0 per cent. The proportion of older Australians with a mild limitation was 39.7 per cent.85

4.12 The Committee further notes that the support provided to the 50.7 per cent of Australians aged 65 years and older with a disability is not covered under the NDIS.

4.13 As 50.7 per cent of Australians aged 65 years and older have a disability that is not covered under the NDIS, the Committee acknowledges the statement by the Australian Institute of Health and Welfare that:

Undoubtedly, ageing will present challenges to the health-care system, given the larger number of older people, the fact that many health conditions and associated disability become more common with age, and that older people are higher users of health services.86

80 Australian Bureau of Statistics, Australian Demographic Statistics, June 2017, Australian Demographic Statistics Data Cube: Excel Spreadsheet, cat. No. 3101.0, viewed 09 March 2018.

81 Australian Bureau of Statistics, Population by Age and Sex, Regions of Australia, 2007, Australian Capital Territory, cat. No. 3235.0, viewed 09 March 2018.



84 Australian Bureau of Statistics, Australian Demographic Statistics, June 2017, Australian Demographic Statistics, cat. No. 3101.0, viewed 09 March 2018.

85 Australian Bureau of Statistics, Disability, Ageing and Carers, Australia: Summary of Findings, 2015, cat. No. 4430.0. viewed 13 March 2018, <http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/4430.0Main%20Features302015?opendocument&tabname=Summary&prodno=4430.0&issue=2015&num=&view>

86 Australian Institute of Health and Welfare, Ageing and the Health System: Challenges, Opportunities and Adaptations, 2014, accessed 06 December 2018, <https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx>

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https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx

https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx

http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/4430.0Main%20Features302015?opendocument&tabname=Summary&prodno=4430.0&issue=2015&num=&view

http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/4430.0Main%20Features302015?opendocument&tabname=Summary&prodno=4430.0&issue=2015&num=&view


4.14 However, noting the statistics on the Territory’s ageing population, the Canberra Health Research Institute argued that ‘There are indeed good arguments for a high rate of health expenditure growth in the areas which produce significant improvements in health outcomes. But the arguments that ageing, increasing chronic disease rates and high health price increases are the main reason we need high rates of health expenditure growth are misplaced’.87

4.15 The Committee notes that the ABS forecasts that Australians 65 years and over is projected to increase over the next decades, due to baby boomers turning 65. The Committee further notes that older people are higher uses of the health care system. However, the Committee also acknowledges that the Territory’s median age is younger than the national average.

4.16 Noting the information and statistics presented, the Committee believes that an ageing population can contribute to rising costs to the health care system. However, the Committee further believes that the emphasis placed on the ageing population as a significant contributor to the current health expenditure is misguided, especially when you compared to the ageing population of other jurisdictions.

87 Canberra University Health Research Institute, Submission 15, p. 3.

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5 JURIS DICT IO NAL COMPARI SON

5.1 The Committee examined a number of comparative analysis of health services delivered in each state and territory. This included the Productivity Commission’s Report on Government Services and the AIHW MyHospitals analysis

5.2 The Productivity Commission’s Report inquired into the equity, effectiveness and efficiency of service provision and the performance reporting for primary and community health, ambulance services, public hospitals and mental health management.

5.3 The AIHW MyHospitals is a government-owned website that allows the Australian community to view the performance of more than 1,000 public and private hospitals against indicators such as waiting times in Emergency Departments, waiting times for surgeries, rates of bloodstream infections acquired in hospital, as well as the length of time patients spend in hospital.

REPORT ON GOVERNMENT SERVICES – HEALTH

5.4 The Productivity Commission’s annual Report on Government Services (RoGS) provides information on the equality, effectiveness and efficiency of government services in Australia. The Health section of the 2017 RoGs examines the performance of primary and community health, ambulance services, public hospital and mental health management.

5.5 Under primary and community health, a number of services are examined including general practice, pharmaceutical services, dental services, allied health services, community health services, as well as maternal and child health services. Of these services, the Committee acknowledges the following information provided by the Productivity Commission.

5.6 In 2016-17 the ACT had a total of 320 FTE GPs. This equates to 78.7 FTE GPs per 100,000 people, which is an increase of 1.6 from 2015-16 and 20.6 from 2007-08. The Committee notes that the ACT has the second lowest number of FTE GPs at 320, with the NT being the lowest at 212. The Committee also acknowledges that the ACT has the lowest number of FTE GPs per 100,000 people.88

5.7 In 2016 the ACT had 4.7 FTE public dentists available per 100,000 people, which is a decrease of 2.2 from 2015 and 2.5 from 2011. The Committee notes that the ACT has the lowest number of FTE public dentists, compared to all other states and territory. The Committee further notes that the number of FTE public dentists falls below the national average of 5.7 for 2016.89

88 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 10A.8, viewed on 07 May 2018, <https://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health>

89 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 10A.22, viewed on 07 May 2018.

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5.8 In 2016 the ACT had 23.6 FTE occupational therapists per 100,000 people, which is a decrease of 3.5 from 2015 and 3.7 from 2012. The Committee notes that the ACT has the third lowest number of FTE occupational therapists, with Tasmania being the second lowest at 23.3 and NSW the lowest at 22.0 FTE occupational therapists per 100,000 people. The Committee further notes that the number of FTE occupational therapists in the ACT falls below the national average of 25.7 for 2016.90

5.9 In 2016 the ACT had 52.9 FTE psychologists per 100,000 people, which is an increase of 1.9 from 2015 and 11.4 from 2012. The Committee notes that the ACT has the highest number of FTE psychologists per 100,000 people amongst all states and territories. The Committee further notes that the number of FTE psychologist is significantly higher than the national average of 24.2 for 2016.91

5.10 With regards to the performance of ACT public hospitals, the Committee notes the following information provided by the Productivity Commission.

5.11 In 2015-16, ACT public hospital expenditure was $3674.9 per person, which is an increase of $814.3 from 2014-15 and $1939.5 from 2006-07. The Committee notes that the ACT has the highest expenditure per person for public hospital services. The Committee also acknowledges that ACT public hospital expenditure is significantly higher than the national average of $2550.9 per person.92

5.12 In 2015-16, available beds per 1000 people in ACT public hospitals was 2.8, which has remained unchanged from 2014-15 and is an increase of 0.5 from 2006-07. The Committee notes that the ACT has the highest amount of available beds per 1000 people, along with NSW and South Australia. The Committee further notes that the number of available beds per 1000 people in ACT public hospitals is above the national average of 2.6 for 2015-16.93

5.13 In 2016-17 public hospital separations per 1000 people in the ACT was 280.1, which is an increase of 12.9 from 2014-15 and 35.3 from 2006-07. The Committee notes that the ACT has the second highest number of public hospital separations per 1000, with the NT being the highest at 666.9 for 2015-16. The Committee further notes that the number of public hospital separations per 1000 in is above the national average of 246.9 for 2015-16.94

5.14 In 2016-17 the proportion of patients seen on time in ACT emergency departments was 62 per cent, which is an increase of 4 per cent from 2007-08. The Committee notes that data was not provided to the Productivity Commission for the 2015-16 period. However, the Committee acknowledges that based on the information provided to the Productivity Commission, for 2016-17 the ACT has the second lowest percentage of patients seen on time,

90 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 10A.24, viewed on 07 May 2018.91 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 10A.24, viewed on 07 May 2018.92 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 12A.2, viewed on 08 May 2018.93 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 12A.4, viewed on 08 May 2018.94 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 12A.6, viewed on 08 May 2018.

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behind the NT at 61 per cent. The Committee also acknowledges that the ACT falls below the national average of 73 per cent of emergency department patients seen on time in 2016-17.95

5.15 The Committee notes that in early 2017, ACT Health was unable to provide data on emergency department performance, elective surgery waiting times and mental health data for the 2017 RoGS. As a result, ACT Health ordered a comprehensive System-Wide Data Review, which commenced in March 2017. In August 2018, the Minister tabled the System-Wide Data Review, as well as an Implementation Plan that outlines the program of work over the next three years.

5.16 The Committee notes that it is striking that the ACT has less than the national average of most allied health services including GPs, dentists and occupational therapists.

Recommendation 9

5.17 The Committee recommends that, as the ACT has less than the national in average primary and community health services providers, the ACT Government develop a workforce strategy to build on existing numbers.

AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE

5.18 The AIHW MyHospitals website reports on results and measures underpinned by the Performance Accountability Framework. The Framework was endorsed by the Council of Australian Governments in late 2011 and released in May 2012, and identifies 48 indicators against which performance will be measured under the domains of equity, effectiveness and efficiency. There are 17 hospitals indicators and 31 indicators for primary health care organisations.

5.19 Under elective surgery, the treating doctor determines how urgently surgery is needed, then assigns the patient to one of three elective surgery urgency categories – Category 1 (surgery is recommended within 30 days), Category 2 (surgery is recommended within 90 days), or Category 3 (surgery is recommended within 365 days). Under these three categories, the Committee acknowledges the following information provided by the AIHW.

5.20 In 2017-18, 91 per cent of patients received Category 1 surgery within 30 days at the Canberra Hospital, compared to its national peer group performance of 93 per cent.96 Alternatively, 92 per cent of patients received Category 1 surgery within 30 days at Calvary Public Hospital, compared to its national peer group performance of 97 per cent.97

95 Productivity Commission, Report on Government Services 2017, Volume E: Health, Table 12A.13, viewed on 08 May 2018.96 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Waiting Times for Surgery, viewed on 10

October 2018, <https://www.myhospitals.gov.au/hospital/810000082/the-canberra-hospital/waiting-times-elective-surgery>

97 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Waiting Times for Surgery, viewed on 10 October 2018, <https://www.myhospitals.gov.au/hospital/810000083/calvary-public-hospital/waiting-times-elective-surgery>.

29

https://www.myhospitals.gov.au/hospital/810000083/calvary-public-hospital/waiting-times-elective-surgery

https://www.myhospitals.gov.au/hospital/810000083/calvary-public-hospital/waiting-times-elective-surgery

https://www.myhospitals.gov.au/hospital/810000082/the-canberra-hospital/waiting-times-elective-surgery

https://www.myhospitals.gov.au/hospital/810000082/the-canberra-hospital/waiting-times-elective-surgery


5.21 In 2017-18, 72 per cent of patients received Category 2 surgery within 90 days at the Canberra Hospital, compared to its national peer group performance of 85 per cent.98 Alternatively,67 per cent of patients received Category 2 surgery within 90 days at Calvary Public Hospital, compared to its national peer group performance of 85 per cent99

5.22 In 2017-18, 75 per cent of patients received Category 3 surgery within 365 days at the Canberra Hospital, compared to its national peer group performance of 91 per cent.100 Alternatively, 79 per cent of patients received Category 3 surgery within 365 days at Calvary Public Hospital, compared to its national peer group performance of 94 per cent101

5.23 With regards to hospital admissions, the Committee notes the following categories identified by the AHIW including childbirth, surgical, medical, other acute care, mental health, rehabilitation care, palliative care and other subacute and non-acute care.

5.24 In 2016–17, there were a total of 1,503 stays at the Canberra Hospital for vaginal delivery. The average length of overnight stays was 2.1 days, compared to its national peer group performance of 2.3 days.102 Alternatively, there were a total of 631 stays at Calvary Public Hospital for vaginal delivery, of which the average length of overnight stays was 1.9 days, compared to its national peer group performance of 2.3 days103

5.25 In 2016–17, there were a total of 616 stays at the Canberra Hospital for caesarean delivery. The average length of overnight stays was 3.3 days, compared to its national peer group performance of 3.4 days.104 Alternatively, there were a total of 316 stays at Calvary Public Hospital for caesarean delivery, of which the average length of overnight stays was 3.2 days, compared to its national peer group performance of 3.3 days105

5.26 In 2016–17, there were a total of 175 stays at the Canberra Hospital for heart failure (without complications). The average length of overnight stays was 4.3 days, compared to its national peer group performance of 4.1 days.106 Alternatively, there were a total of 106 stays at the Calvary Public Hospital for heart failure, of which the average length of overnight stays was 4.7 days, compared to its national peer group performance of 4.0 days107

98 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Waiting Times for Surgery, viewed on 10 October 2018.

99 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Waiting Times for Surgery, viewed on 10 October 2018.

100 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Waiting Times for Surgery, viewed on 10 October 2018.

101 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Waiting Times for Surgery, viewed on 10 October 2018.

102 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Length of Stay in Hospital: Childbirth, viewed on 10 October 2018.

103 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Length of Stay in Hospital: Childbirth, viewed on 10 October 2018.

104 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Length of Stay in Hospital: Childbirth, viewed on 10 October 2018.

105 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Length of Stay in Hospital: Childbirth, viewed on 10 October 2018.

106 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Length of Stay in Hospital: Selected Medical Conditions, viewed on 10 October 2018.

107 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Length of Stay in Hospital: Selected Medical Conditions, viewed on 10 October 2018.

30


5.27 In 2016–17, there were a total of 279 stays at the Canberra Hospital for Chronic Obstructive Pulmonary Disease. The average length of overnight stays was 4.8 days, compared to its national peer group performance of 3.9 days.108 Alternatively, there were a total of 233 stays at the Calvary Public Hospital for Chronic Obstructive Pulmonary Disease, of which the average length of overnight stays was 4.3 days, compared to its national peer group performance of 3.7 days.109

5.28 In 2016–17, there were a total of 318 stays at the Canberra Hospital for appendix removal. The average length of overnight stays was 2.2 days, compared to its national peer group performance of 2.1 days.110 Alternatively, there were a total of 170 stays at the Calvary Public Hospital for appendix removal, of which the average length of overnight stays was 1.6 days, compared to its national peer group performance of 1.9 days.111

5.29 In 2016–17, there were a total of 165 stays at the Canberra Hospital for knee replacement. The average length of overnight stays was 6.2 days, compared to its national peer group performance of 4.7 days.112 Alternatively, there were a total of 69 stays at the Calvary Public Hospital for knee replacement, of which the average length of overnight stays was 4.4 days, compared to its national peer group performance of 4.1 days.113

5.30 With regards to time spent in Emergency Departments, the Committee notes the following information provided by the AIHW.

5.31 In 2017–18, the median length of time for all patients to depart the Canberra hospital’s Emergency Department was 3 hours 34 minutes. The length of time until most patients (90 per cent) had departed was 8 hours 35 minutes, compared to its national peer group performance of 8 hours 14 minutes.114 Alternatively, the median length of time for all patients to depart Calvary Public Hospital’s Emergency Department was 2 hours and 44 minutes. The length of stay until most patients (90 per cent) had departed was 6 hours and 40 minutes, compared to its national peer group performance of 7 hours and 38 minutes.115

5.32 Due to the variations between the ACT and the peer group average in a number of ACT hospital services, the Committee queried whether that additional health expenditure may not just be representative of costs associated to internal ACT residents but the larger catchment area, which would include residents of NSW.

108 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Length of Stay in Hospital: Selected Medical Conditions, viewed on 10 October 2018.

109 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Length of Stay in Hospital: Selected Medical Conditions, viewed on 10 October 2018.

110 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Length of Stay in Hospital: Selected Surgical Procedures, viewed on 10 October 2018.

111 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Length of Stay in Hospital: Selected Surgical Procedures, viewed on 10 October 2018.

112 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Length of Stay in Hospital: Selected Surgical Procedures, viewed on 10 October 2018.

113 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Length of Stay in Hospital: Selected Surgical Procedures, viewed on 10 October 2018.

114 Australian Institute of Health and Welfare, My Hospitals: The Canberra Hospital Time Spent in Emergency Departments, viewed on 10 October 2018.

115 Australian Institute of Health and Welfare, My Hospitals: Calvary Public Hospital Time Spent in Emergency Departments, viewed on 10 October 2018.

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Recommendation 10

5.33 The Committee recommends that the ACT Government investigate what the contributing factors are that cause the highest costs to the Canberra Hospital, as well as Calvary Public Hospital.

5.34 The Committee further recommends that the ACT Government report back to the Legislative Assembly the cost analysis by the last sitting day of 2019.

Recommendation 115.35 The Committee recommends that the ACT Government establish procedures and protocols

to ensure patients treated on time in emergency departments meet the national average benchmark.

Recommendation 125.36 The Committee recommends that the ACT Government establish procedures and protocols

to ensure patients receive elective surgery in accordance with the national average benchmark

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6 STRATEG IES ADOP TED IN OTHE R JURIS DICT IO NS

6.1 The Committee acknowledges that the future sustainability of the health care system is one of the most significant challenges facing the health sector nationwide. With a growing population, as well as a shift in population demographics, increased chronic disease and the increasing costs of technology, the demand on the health system fiscally and physically is becoming unsustainable.

6.2 The Committee examined a number of heath sustainability reviews conducted by other states and territory. This includes the Queensland Clinical Senate’s March 2016 Meeting Report (Queensland Meeting Report) and the Western Australia (WA) Department of Health’s Sustainable Health Review.

6.3 The Queensland Meeting Report inquired into Value-Based Healthcare: Shifting form Volume to Value. The review examined opportunities clinicians and health care executives can take to move resources away from low-value to high-value models of care.

6.4 The WA Department of Health’s Sustainable Health Review, which was to be completed by the end of 2018, aims to provide guidance and direct the WA health system in delivering a patient first, innovative and sustainable health care system.

QUEENSLAND CLINICAL SENATE – VALUE-BASED HEALTHCARE: SHIFTING FROM VOLUME TO VALUE

6.5 The Queensland Clinical Senate was established in 2008 as a forum for clinicians across the state to consider strategic clinical issues and make recommendations to Queensland Health about how to deliver the best care to Queenslanders.116

6.6 The Queensland Clinical Senate allows clinicians to actively contribute to decision making around the design and delivery of quality health services through all levels of the health system in Queensland.117

116 Queensland Clinical Senate, Activity Report 2015-16, viewed 14 March 2018, <https://www.health.qld.gov.au/__data/assets/pdf_file/0019/441640/qcs-activity-report.pdf>

117 Queensland Clinical Senate, Activity Report 2015-16, viewed 14 March 2018.

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6.7 The Queensland Clinical Senate holds a number of forums throughout the year that consider complex and challenging topics. Subject matters examined during these forums are influenced by current strategic delivery issues that are of concern to the community, clinicians and health system administrators.

6.8 On 17 and 18 March 2016, the Queensland Clinical Senate and key stakeholders from across the health system met to discuss the importance of value-based health care. As a result of this forum, the Queensland Clinical Senate presented a meeting report highlighting the current perspectives on value-based models of care.

6.9 The Queensland Meeting Report identified two approaches to care; high-value care and low-value care. High-value generates a large amount of health benefit for individuals and community for the resources invested. Alternatively, low-value care delivers little or no health benefit for an investment of resources. On occasions health care can actually lead to harm.118

6.10 As a result of this March 2016 forum, Senate members and guests examined a number low-value care strategies and discussed approaches in reducing investment. The three significant low-value strategies examined were:

Medical – avoid imaging for patients with non-specific acute low back pain and no ‘red-flag’ indicators of a serious cause;

Nursing – avoid routine non-targeted risk screening (such as Waterlow Score, dysphagia screening tools etc.) for admitted patients; and

Allied Health – allow suitable patients to be discharged for outpatients’ specialist waiting lists after primary contact allied health intervention.119

6.11 As a result of the Queensland Clinical Senate Value-Based Health care forum, local Hospital and Health Services have adopted value based health care principles, including:

Gold Coast Hospital and Health Service and the Royal Brisbane Women’s Hospital partnering with Choosing Wisely to reduce low-value care;

A large multi-site project is underway to identify dietetics opportunities; and

Metro North Hospital and Health Service investment in Value Based Health care program 2017.120

6.12 In their submission, the Health Care Consumers Association encouraged members of the Committee to consider the merits of a similar process utilised in Queensland. In this process, ACT clinicians, consumers and health services could be invited to identify priority examples of low-value health care in the ACT and develop practical action plans to no longer perform in the low-value procedures. Health Care Consumers Association further noted that the ACT has a

118 Queensland Clinical Senate, Value-Based Healthcare – Shifting from Volume to Value, Meeting Report March 2016, viewed 14 March 2018,< https://www.health.qld.gov.au/clinical-practice/engagement/clinical-senate?a=164313>

119 Queensland Clinical Senate, Value-Based Healthcare – Shifting from Volume to Value, Meeting Report March 2016, viewed 14 March 2018.

120 Queensland Clinical Senate, Activity Report 2015-16, viewed 14 March 2018.

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Clinical Council, which would be well-placed to consider the issues presented in the Queensland Clinical Senate forum on value-based health care.121

Recommendation 13

6.13 The Committee recommends that the ACT Government, in conjunction with Health Care Consumers Association, establish a forum to discuss value-based health care.

WESTERN AUSTRALIA SUSTAINABLE HEALTH REVIEW

6.14 In June 2017, the Government of WA announced the Sustainable Health Review. The aim of this review is to prioritise the delivery of patient-centred, high quality and financially sustainable health care across the State. The Final Report was due to the WA Government in November 2018, however it was not made available at the time of the publication of this report.

6.15 In February 2018, the Interim Sustainable Health Review Report was published. The purpose of the Interim Report was to outline initial observations, preliminary direction and recommendation for immediate action, following engagement and consultation with stakeholders.

6.16 The Sustainable Health Review will consider a range of key areas including:

Ways to improve patient pathways and transition including through primary, secondary and tertiary health care;

The mix of services across the system, including sub-acute, step-down, community and other out-of-hospital services to deliver care in the most appropriate setting;

Ways to encourage and drive digital innovation, and the most effective use of new technology, research and data;

Opportunities to drive partnerships across all sectors and levels of government;

Ways to promote safer and more efficient services; and

Implementation of the review’s recommendation in the short, medium and long-term.122

6.17 The Interim Sustainable Health Review Report identified 12 preliminary directions, with nine recommendations for immediate action, as well as areas for further work. These recommendations are expected to commence immediately and will contribute to the next phase of consultation for the Sustainable Health Review Final Report and recommendations.

6.18 In their submission, the Health Care Consumers Association highlighted the importance of public engagement, clinical leadership and partnering with consumers. This approach ensures

121 Health Care Consumers Association, Submission 3, p. 16, 122 Government of Western Australia, Department of Health, Sustainable Health Review, About the Review, viewed 26

March 2018, <http://ww2.health.wa.gov.au/Improving-WA-Health/Sustainable-health-review/About-the-Review>

35

http://ww2.health.wa.gov.au/Improving-WA-Health/Sustainable-health-review/About-the-Review


health care consumers and professionals have ownership of necessary efforts to achieve sustainable health care. The Health Care Consumers Association further noted that the WA Sustainable Health Review is currently examining public engagement, clinical leadership and partnering with consumers. As such, the Health Care Consumers Association suggested that a process similar to the WA Sustainable Health Review would be of significant benefit in the ACT.123

123 Health Care Consumers Association, Submission 3, p. 9

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7 CONCL USIO N

7.1 The Committee notes that ACT Government expenditure on health was $1.63 billion in 2017-18, which equates to 31 per cent of the ACT Budget, and is the largest proportion of expenditure compared to any other output.

7.2 The Committee acknowledges the importance of ensuring that the future trajectory of health funding remains sustainable, while maintaining high-quality services and good health outcomes for the ACT community.

7.3 The Committee further acknowledges that the ACT is not the only Australian jurisdictions that has recognised that continued health expenditure growth will result in an unsustainable portion of state expenditure.

7.4 The Committee, as a consequence of this Inquiry, has made 13 recommendations, which the Committee considers will support, enhance and improve the future sustainability of health funding in the ACT.

Ms Bec Cody MLAChair

11 December 2018

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APPE NDIX A – SUBMI SS IO NS

Submission Number Submitter Received

01 Submission not for Publication -

02 Australian Physiotherapy Association 06 February 2018

03 Health Care Consumers Association 20 February 2018

04 Council of the Ageing 20 February 2018

05 ACT Government 20 February 2018

06 Australian Breastfeeding Association 20 February 2018

07 Cooperatives, Commons and Community Canberra 20 February 2018

08 Capital Health Network 20 February 2018

09 Aids Action Council of the ACT 20 February 2018

10 Community Options 20 February 2018

11 Australian Nursing and Midwifery Federations 20 February 2018

12 ACT Council of Social Services 20 February 2018

13 Public Health Association of Australia 20 February 2018

14 Royal Australasian College of Surgeons 20 February 2018

15 Health Research Institute 20 February 2018

16 Australian Salaried Medical Officers Federation 20 February 2018

17 Australian Medical Association ACT 06 March 2018

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APPE NDIX B – INFOG RAPH IC REFER ENCES

Population: Australian Bureau of Statistics, Australian Demographic Statistics, table 4: Estimated

Resident Population, States and Territories, Cat. No. 3101.0, for the period June 2007 to June 2017, available at: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/3101.0Mar%202018?

OpenDocument

ED Attendances: Productivity Commission, Report on Government Services 2016, 2017 and 2018, table 12A.18: Length of Stay for Emergency Department Care, Proportion of Patients Staying for Four Hours or Less, for the period 2011-12 to 2016-17, available at:

http://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health*Data for emergency department attendance is only available for the periods 2011-12 to 2016-17.

This is a six year period rather than a 10 year period.

Hospital Admissions: Productivity Commission, Report on Government Services 2018: Health, Table

12A.6: Separations, Public (Non-Psychiatric) Hospitals, for the period 2006-07 to 2015-16, available at: http://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health

Births: Australian Bureau of Statistics, Births, Australia 2016, ABS.Stat Datasets: Births, Summary, by State, Cat. No. 3301.0, for the period 2006 to 2016, available at:

http://stat.data.abs.gov.au/Index.aspx?DatasetCode=BIRTHS_SUMMARY

Infrastructure Investment: ACT Health, Health Infrastructure Program, available at:

http://www.health.act.gov.au/public-information/consumers/health-infrastructure-program

Health Spending: ACT Government, 2007-08 Budget Paper No. 4: ACT Health, pg. 153, available at:

http://www.treasury.act.gov.au/budget/budget_2007/files/paper4/10health.pdf

ACT Government, 2010-11 Budget Paper No. 4: ACT Health, pg. 223, available at:


ACT Government, 2014-15 Budget Statement: Health Directorate, Pg. 12, available at:

https://apps.treasury.act.gov.au/__data/assets/pdf_file/0020/601067/Health-Directorate-Budget-Statement.pdf

ACT Government, 2017-18 Budget Statement: Health Directorate, pg. 12, available at: https://apps.treasury.act.gov.au/__data/assets/pdf_file/0007/1069369/C-Budget-Statements.pdf

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https://apps.treasury.act.gov.au/__data/assets/pdf_file/0007/1069369/C-Budget-Statements.pdf





http://www.health.act.gov.au/public-information/consumers/health-infrastructure-program

http://stat.data.abs.gov.au/Index.aspx?DatasetCode=BIRTHS_SUMMARY

http://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health


http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/3101.0Mar%202018?OpenDocument

http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/3101.0Mar%202018?OpenDocument


ACT Public Hospital Expenditure: Productivity Commission, Report on Government Services 2018: Health, Table 12A.2: Recurrent Expenditure Per Person, Public Hospital Services (Including Psychiatric) (2015-16 Dollars), for the period 2006-07 to 2015-16, available at:

http://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health*The expenditure numbers for the ACT include substantial expenditures for NSW residents, and so

the ACT expenditure is overstated.

Growing Population: Australian Bureau of Statistics, Australian Demographic Statistics, table 4:

Estimated Resident Population, States and Territories, Cat. No. 3101.0, for the period June 2007 to June 2017, available at:

http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/3101.0Main+Features1Jun%202017?OpenDocument

Aging Population: Australian Bureau of Statistics, Australian Demographic Statistics, table 58: Estimated Resident Population by Single Year of Age, Australian Capital Territory, Cat. No. 3101.0,

June 2017, available at: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/3101.0Jun%202017?OpenDocument

ACT GP Representation: Productivity Commission, Report on Government Services 2018: Health, table 10A.8: Availability of GPs, for the period 2007-08 to 2016-17, available at:


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http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/3101.0Jun%202017?OpenDocument

http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/3101.0Jun%202017?OpenDocument




committee report - parliament.act.gov.au€¦ · web view3.39the committee recommends that the...

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