transcript of proceedings · 2019-10-02 · transcript of proceedings o/n h-1058521 mr d. howard...

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TRANSCRIPT OF PROCEEDINGS

O/N H-1058521

MR D. HOWARD SC, Commissioner

SYDNEY ROUNDTABLE ON PLANNING AND FUNDING OF TREATMENT SERVICES

SYDNEY 10.13 AM, MONDAY, 16 SEPTEMBER 2019 Continued from 12.9.19 DAY 33 MR N. KELLY appears as counsel assisting the Commission MS L. WALLACE, facilitator FULL PARTICIPANT LIST TO BE FOUND AT END OF TRANSCRIPT


MS L. WALLACE: Welcome everybody to the planning and funding of treatment services roundtable. I would like to start by acknowledging that we’re holding the roundtable today on the lands of the Gadigal people of the Eora Nation and pay my respect to elders present, past and emerging. Thank you very much for coming. My job today is to facilitate the roundtable. A little bit about my background for those 5 that don’t know me, I’m a senior advisor with Nous Group. I’ve been working in management consulting across the health and services sector for about the last 10 years, and before that spent about 30 years or so working in New South Wales Government in various roles, including five years with New South Wales Health. 10 So I just wanted to explain a little bit about the arrangements for today, so everyone is aware of that. You have been provided with a hardcopy of the extra material that went out fairly late on Friday, I think. So there’s a hardcopy been provided underneath your agenda on the table, plus a couple of corrections to the discussion paper which we just wanted to – the Commission wanted to alert you to. So there’s 15 just a single page with some corrections there as well. In terms of today’s proceeding, an audio recording is being made and a transcript of the proceedings will be prepared and placed on the Commission’s website. Participants will have an opportunity to review the transcript before it’s published and make an application for non-publication of portions, but you should assume as we’re having our 20 conversations today that the – any comments that you’re making will be – appear in a public forum. Participants may be accompanied by a legal representative or a colleague, a supporting person, and a number of you have elected to do that. You’re free to 25 consult with that person about any matter being discussed; however, only the participants themselves are asked to speak during the roundtable. I just wanted to be clear about that. So the purpose of the roundtable today is to improve the current planning and funding arrangements related to the provision of alcohol and other drug services. We’ll be working through a series of topics and those topics will be 30 identified in the discussion paper that was sent out in advance, and as part of the discussion paper there was a series of questions really to prompt your thinking about the sort of areas to cover today. My job is to, sort of, make sure that we cover off as many of those as we can but 35 we’ll also be very keen to let the discussion flow. The focus today is primarily at thinking of the future and what things might look like, particularly from a solution perspective. So although obviously we’ll be looking at having conversations as well about some of the issues and some of the problems. We expect there will be some associated matters in relation to governance that will be raised as we go today, 40 although that’s not the primary focus. In order to support the discussions today plus also help our transcription service, I’d like if we could go around the table and just if everyone could introduce themselves and just upfront to identify one particular issue that they’re interested in making sure is covered today. So I might go to my left. Sorry to put you on the spot. 45


MS C. HEWETT: That’s okay. MS WALLACE: So introduce yourself and one issue for today. MS HEWETT: I’m Cate Hewett, CEO of Kamira Drug and Alcohol Rehab for 5 women. Pregnant women is always on the table and the forefront of my mind and how we don’t miss them in our funding and planning contingency, and also, like, just the streamlining of government to State for a small organisation so that we don’t become extinct. Thank you. 10 MS WALLACE: Thank you. Thanks. MR N. HENDERSON: Norm Henderson from Weigelli Aboriginal Corporation. One of the main topics I’m interested in is detoxification services out in western areas. 15 MS HEWETT: Thanks, Norm. DR M. HARROD: My name is Mary Harrod. I’m the CEO of New South Wales Users and Aids Association, and I’m particularly interested in funding of harm 20 reduction services. I don’t see it included in the paper but also looking at prevention and not just prevention of – including harm prevention as part of that. MR S. DOWRICK: Stewart Dowrick, Chief Executive Mid North Coast Local Health District. I guess, and I know it’s in the discussion paper but maybe to share 25 or talk further the issue of the North Coast Collective, which is a different governance and operation model that Glen and I can talk a bit about today or share the early days ..... so it’s actually something different for the future. So - - - MS WALLACE: Yes. Thank you. 30 MS C. COX: Cathryn Cox from the New South Wales Ministry of Health. I think that integration of services planning. MR G. BYRNE: Gerard Byrne, Salvation Army State Manager for Alcohol and 35 Other Drug Services NSW, ACT and Queensland, and I’m interested in funding and planning in terms of how it relates to the gap that occurs between how it is currently and cost escalation just in terms of the usual cost escalations that happen in life, because that gap is widening. 40 DR T. ANDERSON: Teresa Anderson, Chief Executive of Sydney Local Health District and I’m particularly interested in making sure that we have a holistic approach that is multifaceted and particularly looking at the needs of vulnerable families from antenatal to through to a whole of life approach. 45 MR N. KELLY: Nick Kelly, counsel assisting the inquiry, and I am really interested in all of it.


THE COMMISSIONER: I’m glad to hear that, Nick. I’m Dan Howard, the Commissioner, and, likewise, I’m all ears. Thank you. MS E. WOOD: I’m Elizabeth Wood. I’m the Executive Director of System Purchasing in the Ministry, and I’m particularly interested in hearing how some of 5 the services and the planning and provision we can best support with our purchasing and management levers. PROF A. RITTER: I’m Alison Ritter from the Drug Policy Modelling Program at the University of New South Wales. I’m clearly interested in all of it, and in 10 particular I’m interested in thinking about the specific solutions to both the funding and the planning crisis that we’ve currently got. MR L. PIERCE: I’m Larry Pierce, the CEO of the Network of Alcohol and Drug Agencies, the peak body for the non-government drug and alcohol specialist sector in 15 New South Wales, and the same as has been said, the planning and funding system, we believe, is entirely broken down and it would be good to build a new one. DR M. MOORE: Michael Moore from Central and Eastern Sydney Primary Health Network. I’m interested in the entire area but, specifically, our particular interest is 20 best practice contracting. So best practice program funding logistics. So the particular thing that I would be keen to look at would be long-term rolling contracts rather than intermittent contracts that, you know, expire with four weeks notice and that get introduced with four weeks notice. What I’d like to see is ongoing rolling contracts properly monitored, properly managed. 25 DR J. MITCHELL: I’m Jo Mitchell. I’m the Executive Director for the Centre for Population Health at the New South Wales Ministry of Health, and I’m interested in the way that we look at partnerships with – for different interests in this area and how we build those partnerships. 30 MS A. LARKIN: Amanda Larkin, Chief Executive of South Western Sydney Local Health District, and I think there are a couple of elements and the paper talks about those. One of the critical ones, I think, is stigma about how drug and alcohol patients are seen in the system and how they’re treated in the system. I think that’s a really 35 important one, I think, for the roundtable to focus on. The other one probably is a bit of work that we’ve been doing recently with the PHNs, and I think there is a large volume of drug and alcohol work in primary care where, with some support, we can actually deliver quite different models of care going forward, and we’ve done some work around that. 40 MR W. KMET: Walter Kmet, I’m the CEO of Macquarie University Hospital and Clinical Services, but formerly the CEO of Western Sydney Primary Health Network, WentWest. It’s with that interest that I look forward to talking about integration of care and particularly in relation to continuity of care and how we 45 actually, you know, reduce a system of silos so continuity care can actually be put in place.


MS G. JAMES: I’m Glen James. I’m the Executive Director for Mental Health and AOD for North Coast PHN, so I’m really interested in the rural and regional approach in funding and the inequity of funding between metro and rural and regional areas, and also, as Stewart talked about, the North Coast Collective and the work that we’re doing in co-commissioning and funding. 5 MS WALLACE: Thank you, everybody. Just wanted to note that the Commonwealth Department of Health was invited to participate in today’s round table and declined. There is a letter in the additional material from Lisa Studdert who’s deputy secretary, Department of Health. So just wanted to make sure 10 everyone was aware of that. In terms of sort of working together today, as you can tell from the introductions around the table, it’s a lot of experience and expertise sitting around the table, and people will bring a lot of different perspectives. We’re very keen to hear your views. As I mentioned at the start, the Commission is – particularly at this point of time in the inquiry, is interested about particularly 15 thinking about the way forward in terms of planning and funding. So I want to make sure that everyone feels that you have the opportunity to actively contribute that expertise and experience. In terms of the transcription service, we just want to make sure that it’s one voice at a time. It makes it a lot easier to do the 20 transcription, but, obviously, goes without saying, respecting each other’s views around the table. My job is to make sure that everyone gets an opportunity to contribute what they want to contribute, but that we also finish on time at 4.15. Are there any questions, before I hand over to the Commissioner to make some introductory remarks – any questions about today, how it’s going to operate at this 25 point? Yes. Might hand over to Dan now to make some introductory remarks. THE COMMISSIONER: Thank you, Leanne. Can I welcome everyone here and say how grateful I am that so many people who have such a wealth of experience in this area have been able to come to assist the Commission today with this very 30 important aspect of our work. I would also like to thank Leanne for being available to facilitate this meeting. Having someone with her skills is a great help for this round table hearing. As you would all know, this inquiry is a Special Commission of Inquiry, and we came into existence at the end of last November, and we really got up and running with premises and our establishment staff probably in February, and 35 since then, we’ve had a number of hearings. You’re probably aware we’ve been going around the state to various regions that we could tell or expected from the data and the BOCSAR and other statistics suggested that they were having trouble with amphetamines. The inquiry, of course, is charged 40 with looking at specifically ice, crystal methamphetamine and amphetamine-type stimulants. Initially, it was just focusing on crystal methamphetamine, but I requested that the terms of reference be extended to all amphetamine-type stimulants because that introduces MDMA, ecstasy, the – a much wider range of substances, and I felt that was really important because if we’re going to be doing the work, we 45 may as well be able to speak to a range of drugs that will inform drug policy more generally, and it seemed to me that that was a fair way to focus looking at all


amphetamine-type stimulants to actually make some useful recommendations about those would also inform a drug policy generally. So one of the terms of reference in my letters patent to inquire into options to strengthen New South Wales’ response to ice and illicit amphetamine-type stimulants including law enforcement, education, treatment and rehabilitation, and those last two, of course, are, essentially, where this 5 round table comes in. Obviously, funding seems to be the critical issue all the time in terms of policy actually converting into programs and treatment on the ground, and going around the various regions, as I have, I’ve really – I’ve got a number of early impressions that I 10 won’t say are final, and they’re not – merely at the stage of recommendations yet, but it’s very clear to my impression that services are struggling. There’s – not all services, but many services in this area are struggling. The demand exceeds the ability of the services to meet that demand, and in some places, there simply aren’t effective services. It’s very hard, in some of our regions, to gain access to the 15 required detoxification facility or rehabilitation facility, and I’ve heard a lot of evidence about not just the sparseness of treatment facilities in various locations, but also the complexity of funding and how difficult providers of services have found it to spread their funding to meet all the needs that are being – and demands that have been made on their services. 20 From what I’ve seen so far, funding is complex across the Commonwealth and the states. There is some communication difficulty. There are gaps that arise because of that. There appears to be no overall drug and alcohol funding strategy in New South Wales, let alone an overall drug and alcohol strategy. It’s interesting that 20 years 25 ago, we had a Drug Summit where strategies and plans and programs and funding very much came into bang on the heel of that program. So the Drug Summit seemed to be met with real will and determination to solved problems that were very apparent and made apparent by that drug summit. I think I’m seeing some similar things in my inquiry so far. I’ve seen a lot of problems that aren’t being addressed. 30 There seems to have been a lack of overall strategic planning to inform initiatives and funding. So at best, funding seems to be clunky, and at worst – and, at times, it seems to be Byzantine. No. in saying that, I’m not meaning to be critical of any service provider 35 or any funder, but there clearly is a lot of work to be done, and I – I would be very concerned if this inquiry wants to make meaningful recommendations about drug policy relating to amphetamine-type stimulants. There’s very little point in me making any recommendations unless the planning and the funding follow the proposals. So with that, it was very clear to me that it was vital that we have this 40 discussion today, and I’m so pleased to have all of you at the table so I can hear what you see the problems as being. I can hear what you see as possible ways forward, how we can bridge the communication gap, how we can get people on the same page where they need to be and how we can ensure that services actually get to where they are needed when they are needed. 45


I know we’re all – resources are always strained. I understand that. But it seems to me that we can probably do better, and I’m hoping that this meeting will give me some real insights into ways that we might do better. I would like to that counsel assisting, Nicholas Kelly and his team for putting together this very excellent brief which, I think, encapsulates the key issues that we need to discuss today, and I very 5 much look forward to your input in the discussions that Leanne will facilitate for us. So thank you. Thanks. MS WALLACE: Yes. Are there any questions of the Commissioner at this point of – in terms of Dan’s role, today, he will ask questions at points of time when he would 10 like to ask questions. So, obviously, particularly thinking about some of the issues for the inquiry that are pertinent for today’s discussions. So we might then move on to the first topic. So the first topic is about how to improve the planning of alcohol and drug services, and we want to focus as two 15 levels: at a government level, so particularly thinking about state-wide and then the interaction from a national perspective, and then we’ll – so we will do that discussion first, and then we’ll follow on to have a conversation about planning at the local level, and that’s particularly – and thank you to Glen and Stewart for offering because we’re keen to hear about – particularly how that works across the PHNs and 20 the local health districts and across into the non-government sector as well. But we wanted to start at the government level in terms of thinking about planning there. Jo, I’m wondering if you would be happy to make some introductory remarks, just around how planning for alcohol and other drug services currently operates in 25 New South Wales, sort of – and if there’s any insight you can give in terms of what that might look like in the future as well would be useful. DR MITCHELL: Okay. So if – I would like to say some preliminary remarks as well, and so certainly having – clearly following the deliberations of inquiry. I think 30 there are probably a few contextual points that I would like to make before we go into the planning focus - - - MS WALLACE: Sure. 35 DR MITCHELL: - - - one of which I’ve heard around this table today, which is that we need to look at alcohol and other drug use as a whole and recognise that alcohol remains the – has a higher contribution to ill health in our community as well and the burden of disease. I’ve seen that reflected in some of the transcripts that I’ve read and in some of the submissions as well, so I think this table is very aware of that part 40 of the context. We also agree that it’s important to look at a range of drug use, given that drug use patterns change over time and given also that people use a combination of drugs as well, that it’s not just the one substance. So looking more broadly, I think, is incredibly important, particularly if we are talking about the planning and funding side of things as well. 45


Another comment, too, is that alcohol and drug services happen across a range of settings. So we have people here from general practice. It happens in our drug and alcohol services, in the LHDs. It happens in non-government organisations. It happens in general practice, within the local health district as well. It also doesn’t just happen in the AOD services but, in fact, across a range of services, such as 5 mental health, ED, maternity services as well. And, again, I think this is probably a truism for the people around the table, but important for us not to forget that. And, similarly, that there’s a range of different kinds of treatment that are relevant and appropriate. So it’s not just one kind of treatment but we’d actually need to look at a range of modalities. So I think that, as we’re talking today, it’s important for us to be 10 thinking about that sort of broader context as well. The final thing that I would say as well is that there is significant service provision across the state which happens through a range of those range of organisations, but New South Wales Health it’s sort of very well documented and certainly through a 15 range of inquiries acknowledged that there is significant unmet need as well. So I thought then, just to give – to start the discussion, that it’s probably worth talking about some of the things that we do in New South Wales Health around our planning for drug and alcohol and how that sort of interacts, and so if I give that as general introduction. I mean, clearly then the local health districts will jump into around 20 some of the local planning that happens at the regional level. So the first thing that I would mention is that we have the New South Wales Health strategic priorities, and drug and alcohol is one of the key priorities within the ministry’s strategy. For AOD, we’ve been working over the last several years to 25 look at how we have a more integrated system, but our focus particularly has been around pregnant women, the opioid treatment program and consultant and liaison. So they’re some of the particular focal points for us over the last couple of years, and certainly over into the next financial – this current financial year. So that’s one of the guiding documents for us and, of course, I should have mentioned that we also 30 are guided by the National Drug Strategy as well. So then the next layer for us is then around – we’ve had a number of enhancements of funding over the last several years and the most recent of those was the 2016 Drug Package, and the focus on the Drug Package was around substance use in pregnancy, 35 as well as young people, as well as families, in particular. And so the way in which we were able to look at the way to roll out that program of funding included a number of different mechanisms. The first thing that I would say is that the New South Wales Government led a number of round tables where they talked to a range of government agencies and experts across the state to identify those funding 40 priorities, and then the government commitment was made. And then after that the New South Wales Ministry of Health went through a number of processes to determine the best way to put that funding into action. So as example would be – well, two examples relate to the substance use in pregnancy funding and 45 also the youth – the youth support funding. Each of these plans for how we went forward to those – the funding into effect included looking at doing a review of


evidence around, you know, what the evidence is telling us around these services, significant consultation which would happen with service providers and other agencies. We would then develop the specifications and then tender for those services, and then put into place performance monitoring processes to ensure that that was happening in the way that had been intended. So for each of those pockets 5 of money, there was a process to make decisions about the way in which that would be rolled out. Another area that the Ministry looks at in terms of shaping the drug and alcohol service continuum is our work on clinical guidelines, and so an example of that is the 10 release of the new Opioid Treatment Program guidelines which happened most recently, and again, that sort of followed a similar process of evidence review, very strong clinical consensus, then training for clinicians and then, again, performance metrics to start to shift some of the practice that we see through that program. And one of the particular things that we’re interested there is shifting from methadone to 15 buprenorphine when it was clinically indicated, and so we’ve been able to see that there has been that shift. So using those kinds of instruments then helped us to make – to support changes in clinical practice that we know is important for us to do based on the evidence. So that’s another mechanism that we use to shape the service system. 20 MS WALLACE: So you’ve – I mean, you’ve made reference to the National Drug Strategy and you’ve been describing, I suppose at a particular service planning level, the things that you put in place, but I think from evidence from – the Inquiry and also at the last Health Roundtable, the absence of what sits in the middle of that for New 25 South Wales has come up quite strongly. And obviously, as part of the supplementary material we received a copy of the draft National Framework for Alcohol, Tobacco and Other Drug Treatment Services as well. So are there any other comments you’d like to make about that sort of – the strategic plan for alcohol and other drug services for New South Wales that sits in between those - - - 30 DR MITCHELL: In between those. MS WALLACE: - - - firs two, yes. 35 DR MITCHELL: Look, I know that at the Funding Roundtable there – sorry, at the Health Services Roundtable there was discussion about the New South Wales strategic document, which is in a draft form. MS WALLACE: Right. 40 DR MITCHELL: And that, again, has looked at the broad direction for New South Wales Health and it remains that the outcomes of this Inquiry and other inquiries will help us to shape that as well. 45 MS WALLACE: Yes.


DR MITCHELL: So I think it’s fair to say that some of the people around the table and certainly into the broader service system, that there’s been quite a lot of work on that document and that, even though it’s not released, it is something that’s still guiding the work that we do as a Ministry and shapes the policy work of our team. 5 MS WALLACE: Yes. THE COMMISSIONER: Thank you, Jo. That’s very interesting. DR MITCHELL: Can I just mention - - - 10 MS WALLACE: Sure. DR MITCHELL: And I won’t go into the details now because I think that they’re – in terms of, you know, having the broader discussion, just a couple of other things 15 which does guide the work that we do at the Ministry. Another area that’s very important for us is around building innovation and looking at innovative models and treatment models in particular, and I’m sure that the Commission has heard of the translational research grants program, which is a mechanism again by which we can look to testing innovation and then looking at how we can influence the system as a 20 whole. Within the Ministry over the last year or so we’ve been doing more work focusing on consumer input, and that’s an area that we really are wanting to build on because we think that that’s another part of the puzzle in terms of the services that we provide, and Amanda has raised already the issue of stigma and discrimination, which we think is very important, and so that’s also an area that we’re very interested 25 in as well. So I think that those two elements are also areas that warrant further discussion as well about how that influences change. MS WALLACE: Yes. Thank you. Larry, I wonder whether you might like to make some comments around that State-wide picture and how it could best 30 contribute to planning for services going forward. MR PIERCE: Sure, I would. And I’d like to thank Jo for the overview and I guess I would just add that that’s all being done within the sum of constraints, so within the existing service infrastructure, the existing budget structures and so on. She 35 mentioned the drug package but that was politically led by the Minister of the day and expressed some of her priorities. That was Pru Goward, which was a very good thing. But I think I go back to Dan’s statement earlier; 20 years ago we had a drug summit in this State that was a highly politically driven process that did resolve in a transformation and reformation of the drug and alcohol services system in New 40 South Wales. It became across the whole of government process with an oversight body in the Department of Premier and Cabinet – the Office of Drug Policy, I think they called it. And then Health was the major beneficiary of the large amount of funding that came out of that evidentiary review process that took place in the context of a parliamentary drug summit, so a sitting of parliament. 45


Other line agencies like police, FACS, Housing, etcetera, were all involved and had funding and direction. A very comprehensive plan of action was produced that overlaid, if you like, all of the strategic planning and priorities that had already happened in the State linked to the National Drug Strategy and the partnership arrangements with the Commonwealth. That process did result in a transformation 5 of the way in which business was done in drug and alcohol, and central government oversight through the Premier and Cabinet Office was essential for ensuring that Health was able to work effectively with FACS and Housing the criminal justice system and the police and so on. 10 It kind of reminded me of 20 years before that when the Hawke government had the first national summit and Neal Blewett, who was the Federal Health Minister at the time, created a national strategy that was linked and coordinated with the State and Territory governments that did subsequent State and Territory based drug and alcohol strategies that had never been done in that way in the past. Both of those 15 things illustrate to me the importance of political leadership in drug and alcohol, because, let’s face it, this is the most over politicised program in Health. In no other part of the Health Department would you get priorities being directed by a Premier or a Health Minister than in drug and alcohol. In no other program are the constraints around what can be done politically overdetermined. 20 So for me, the context that’s missing in New South Wales at the moment is (1) a commitment to a whole of government approach to drug and alcohol service planning that integrates well with the community housing and social services system and the criminal justice system in particular, and one that is reflective and based on a 25 population based method for planning and that results in an allocation of resources to where they’re best utilised and who the best providers are. And I think we need to go back to the drawing board, really, to do that. The current strategic plan that Jo mentioned, and because she’s a public servant she can’t say what I’m going to say, is kind of dead in the water because we’ve got a Minister who doesn’t – no disrespect 30 to Brad Hazzard but he doesn’t have a clear idea of what it ought to be, and, therefore, it’s sitting on a shelf starved of any attention. And so what we’re doing in the interim is what we do best, and I commend my colleagues in the Health Department in the Population Health branch because they’re doing some incredibly good work within, as I said, the kind of sum of constraints. So I think I’ll leave it 35 there. MS WALLACE: Thank you. So I’m going to open it up now in terms of how – the question about how could strategic planning be done better in New South Wales. Jo has given us that important context in terms of some of the important things that New 40 South Wales Health is doing and Larry’s obviously made some clear points about reflecting on what’s gone in the past and the sort of things that are missing from what’s happening at the moment, but I’m interested in further comments around the total – we are going to move to the local planning level shortly but I’m interested at a State-wide level any other comments people want to make about how could strategic 45 planning be done better at a State level. Michael.


DR MOORE: I think there’s an elephant that’s not in the room, and that’s - - - MS WALLACE: Yes. DR MOORE: - - - Federal Government. 5 MS WALLACE: Yes. DR MOORE: So, you know, Australia is a federation of States. 10 MS WALLACE: Yes. DR MOORE: And we tend to forget that, and we’re not one of the better organised federations in the world. I mean, there are other federated States around the world – Germany, Canada – and my particular experience is observing what goes on in 15 Health, and you see Commonwealth and State Governments interfering with each other all the time. That doesn’t look like a well organised federation. So I think there’s - - - MS WALLACE: Yes. 20 DR MOORE: There’s an issue that’s bigger than us here. MS WALLACE: Yes. 25 DR MOORE: Which is we need to have a look at the Australian federation and work out how to make it better because, certainly, in – I don’t know how things work in, you know, education and police. Maybe it works better. But, certainly, in health, my observation is it doesn’t work that well, and we need to have a think about what being a federation means. 30 MS WALLACE: And how that operates. DR MOORE: Yes. 35 MS WALLACE: Yes. Absolutely. Yes. DR MOORE: And why aren’t the Australian government here? Why aren’t they here? You know, this is one-third of Australia, and we’re talking about a major issue, and they’re not here. Why is that? And I’m - - - 40 MR KMET: And it’s ..... shared program. DR MOORE: And it’s not because they don’t want to be. It’s because they’re not resourced to be here. 45 MS WALLACE: Yes. So Glen and then Walter.


MS JAMES: Okay. I just want to note that there is an inequitable distribution of AOD funding in services in New South Wales, and this means that some groups of population including rural and regional communities have less access to appropriate services, especially in AOD, and that’s a grave concern because I do represent the regional PHNs as well, but coming from Western Australian coming to New South 5 Wales, I’ve actually noticed that there’s much more tension around the state and Commonwealth jurisdictions and responsibilities, and I think this really needs to be addressed, and moving on from Michael’s statements that this needs to be addressed, and because of the LHDs – you know, there’s multiple LHDs. I mean, we deal with two in our regions. Whereas, in some of the other states, you know, the LHD system 10 is not as fragmented as well. So I think, you know, one of the first things we really do need to address is the coordination and the communication between the Commonwealth and state jurisdictions. It’s just a comment. MS WALLACE: Thank you. Walter. 15 MR KMET: I just want to pick up Michael’s point on cooperation of state and Commonwealth. I think it’s a very important point. Also think when we talk about funding, it’s actually worse than that because in New South Wales, we’ve got an arm’s race of building hospital beds and infrastructure. What that does is actually 20 suck more people into the parts of the system that actually aren’t appropriate for the kinds of people we’re talking about here. So there’s real opportunity cost, when we’re talking about funding, it’s one bucket of money. There are plenty of leaks in the bucket which ..... talk about as part of the day, but it’s 25 also the fact that resources end up getting locked into certain parts of the system providing models of care that aren’t actually the kinds of models of care that are appropriate for the kinds of people we’re talking about, and, as I said, in New South Wales, you know, there’s an issue now, and you’ve got a new hospital in the region I work in in the Northern Beaches, seeing very significant numbers of people that 30 we’re talking about here affected by ice turning up to A&Es, inappropriate place for them to be, ultimately. Discharge planning doesn’t take place well. It can’t take place well. So you end up with a lot of wastage in the system because you’re building a system that’s geared towards the past, not geared towards the future, and then, of course, the ultimate problem is that you get to the point that Michael’s 35 making is, well, actually, when they’re out of hospital, they’re not our responsibility. Talk about ABF and other things and the way that works, but, ultimately, there are different systems operating. MS WALLACE: Okay. 40 MR KMET: And I’m not arguing against hospitals being refurbished and being properly built and everything else. That’s not what I’m arguing, but I’m arguing about the balance of funding. 45 MS WALLACE: And that protected person cost.


MR KMET: Yes. Opportunity cost. MS WALLACE: Yes. Gerard. Yes. MR BYRNE: Yes. Look, I agree with that proposition of, you know, planning in 5 arrears instead of in the future because in the drug and alcohol sector, particularly within the NGO context, we get attention when there’s a crisis. So we don’t have planning, and we don’t have sustainability funding that allows us to build our businesses for the future. The funding framework is almost, for some services, at drip feed level, and, certainly, there is a sense in which, you know, a lot of NGOs 10 bring resources to the table themselves, be that money, properties or whatever, but at the end of the day, the real funding is the operational funding, and it needs to be on a solid business base, and the only way you can do that is like any business. It has to be able to plan for its future. So the NGO sector – our sector – we need to be able to plan for our future, but we can’t do that under the current framework. 15 MS WALLACE: I was going to come to Alison now because we – I mean, a number of people have raised the – this – the intersection between what’s happening at the Commonwealth level and at the state level. So, Alison, would you like to make some comments. 20 MS RITTER: Sure. Thank you. I actually had sort of two overarching comments. The first is in relation to the multiple funders and the issue of role clarity, particularly between the Commonwealth and the state and the instruments of the Commonwealth, the PHNs and, of course, the instruments of the state, the LHDs, and, in my 25 observation, there is a confusion about who is a funder and who is a provider, and that – I mean, I think the LHDs are probably the best example of these – these multiple roles and the lack of role clarity. In 2013 – 2012, actually, the then Health Minister Mark Butler commissioned the review of the way in which the Commonwealth engaged with planned, purchased and monitored alcohol and drug 30 treatment services which is, of course, the New Horizons report, which you have the executive summary of, and I, of course, have brought the full report just in case. There might be something important in there. We really struggled with role clarity. We reviewed the Federal Financial Relations 35 Act. We reviewed all of the federal, state, Health relationships, and, quite frankly, alcohol and drugs does not fit in any of the documented role statements. In theory, the Commonwealth should not be funding tertiary care except through the relationship with the states in relation to hospitals. So there’s a complete mess of roles. Our – sorry. Our assessment at that time was that there was a complete mess 40 of roles. We endeavoured – we’ve got a chapter on role clarity in the full report. We endeavoured to provide some options for consideration regarding the Commonwealth removing itself from the funding of specialist alcohol and drug treatment and confining itself to primary care through its mechanism with either the PHNs and, obviously, through GP funding. 45


That option was not taken up by the Commonwealth, and the end result is that the role clarity has continued to be confused. In relation to the development of the national treatment framework – so we’ve – when I say “we”, I mean the Drug Policy Modelling Program led by myself were commissioned by the Commonwealth to develop the National Treatment Framework. We’ve had a year of consultations. 5 Role clarity has been raised. We’ve consulted with over 250 people in a forum, in focus groups, in Zoom sessions, in individual consultations across the – everybody that’s involved, and role clarity continues to be raised. The original intent of the National Treatment Framework was to specify roles and responsibilities. That was the third dot point under the brief that was provided from the National Drug Strategy 10 ..... committee. In the process of the consultations, it became apparent that it was not up to me to determine whose role things were and that, in fact, there was no authority within the development of the National Treatment Framework to resolve the role confusion. 15 The result is, as you’ve seen, the current draft which remains confidential does not have a statement about roles because it has been unable to be resolved through that particular process, and I think it – to come back to the question about planning, you must resolve roles and have role clarity and partnerships – of course, I’m not ruling those options out at all – before you can think about planning. I have a second 20 comment about data, but I can hold that over, if you like. MS WALLACE: We’re also going to be spending a bit of time talking about the data modelling and those sort of things as well. So we might sort of hold and - - - 25 MS RITTER: Yes. I – the data comment is actually not about that. MS WALLACE: Yes. Okay. Well, now - - - MS RITTER: It’s – so just - - - 30 MS WALLACE: Why don’t you make that comment now because it’s probably - - - MS RITTER: Just really quickly. 35 MS WALLACE: Yes. MS RITTER: We don’t know where treatment for crystal methamphetamine is being provided or treatment for alcohol or other drugs. We’ve done a series of 40 analyses just in the last few months that reveal that our current formal data systems record about 30 per cent of treatment in Australia. So if we’re going to plan, we need to know what currently is and where are people seeking support, advice, assistance to change their relationship with drugs and to reduce harm, and we currently don’t know that, and, therefore, we are planning without knowing where 45 people are currently going, and my second data comment which actually – at least, what Mary said at the beginning is that harm reduction services are part of the


treatment system. They are within the National Treatment Framework explicitly part of the treatment system, and we don’t collect and consider all of the support and interventions that occur as part of harm reduction within our analysis of the treatment system in the broader sense and, therefore, how can we plan if we don’t know what is currently happening. 5 THE COMMISSIONER: Can I just pipe in there, Alison. Since you mentioned the National Framework - - - PROF RITTER: Yes. 10 THE COMMISSIONER: - - - and I understand it’s only a draft, but getting close to a final document, I understand. PROF RITTER: Yes. 15 THE COMMISSIONER: If I look at page 14 of that document, they have the principles for planning, purchasing and resourcing of treatment. And there are a few things under there that are very encouraging to see in the document. For example, they say: 20

Alcohol and other drug treatment planning should –

and dot point 3: 25

Be conducted in a coordinated and joined-up fashion and be resourced to do this.

PROF RITTER: Mmm. 30 THE COMMISSIONER: Further down the page, I think the third last dot point:

This means that the treatment purchasing processes should ensure that funding contracts with service providers are of a length to enable continuity and certainty. 35

Now, both of those dot points are key issues, it seems to me, that I’ve just heard as very serious problems the way things are at the moment. What will – do you have any insights as to what will become of this document if it comes in – if it comes in with these dot points in it, how will they – how would it be anticipated they would be 40 acted on if they’re speaking specifically of things being coordinated, joined up and resourced to do what they have to do? PROF RITTER: Indeed. No. 45 THE COMMISSIONER: Maybe you’re not the - - -


PROF RITTER: No. This is – so this has now actually been – actually not quite this version. Saturday morning the final version was submitted to the Department of Health and it’s almost this – some very minor things. This section on the principles for planning, purchasing and resourcing was drafted very early on and has not substantially changed over the 10 months of consultation. I think we can be very 5 confident that these principles have been endorsed widely, including by the Commonwealth officers that I have worked with. The implementation of these principles is the key issue. We have been asked to prepare an implementation report to identify how the 10 National Treatment Framework will be translated into actions on the ground by whom, and the status of that implementation report is not – I don’t know what will happen. That might be a confidential report that we submit to the department and that’s the end of it. It might be subject to being available to – there’s a working group to the National Treatment Framework and/or it might become available to the 15 National Drug Strategy Steering Committee. We are intending – sorry, I have signed a confidentiality agreement in relation to this piece of work. THE COMMISSIONER: Sure. 20 PROF RITTER: We are hoping to be able to make specific recommendations to both the National Drug Strategy Steering Committing and the Ministerial Alcohol and Drug Forum in relation to actions that would be required to give effect to the principles as documented in the National Treatment Framework. That is our intention. 25 MR KMET: Can I just make a comment about the assumption that is being made that PHNs are the machinery of government. There really is – that’s a problematic assumption, and I think in terms of the way in which PHNs do their work, you know, we try to do our work in a week – former life – try to do our work in a responsive 30 way within a Commonwealth framework, but, I mean, they are different systems in an operational sense, and I think the strategy itself and not unpacking PHNs as entities working in that area, I think, is a mistake. It should be recognised that a lot of – and I talk about the way I think planning should take place. There will be strong views on that, but I think there’s an assumption here that PHNs are part of this 35 machinery of Commonwealth – well, while I’ve only been here, PHNs are, and I think that’s something that needs to be recognised in the way in which we go about our business. MS WALLACE: Did you – Walter, you – yeah. Walter, you – just to let – you had 40 some views about how planning should take place. I’m interested. Is that at the state-wide level or the local level? MR KMET: Well, I have a – I have a strong bias that says there are planning – planning is appropriate for a place. It’s not one thing should happen in one place. I 45 think there are appropriate things that should be planned at the Commonwealth level, at the state level and also at the – you know, at the regional level. And I think the


way in which you do that needs to be informed by the fact that a lot of things being planned, even at the state level, need to recognise that there are various ways in which people might be – there are variation in circumstances at the local level that need to be considered. 5 MS WALLACE: Yes. MR KMET: There are relationships that may be different in different places and I think, you know, when we talk about a model of care or framework of care, often the only way that works is because people have relationships with local that make it 10 work. I mean, publishing a standard or framework is a starting point. It’s not an ending point. I also have a strong view that planning at state level and national level should be about taking – taking policy out of the way so people can get on to do their business. I think often planning results in those levels of results and putting things in place which make it more difficult. ABF is a classic example. I mean, there are so 15 many rules around ABF that don’t allow things to move forward at a local level in terms of the way money is spent. The role of planning should be taking away so people can get on with business as opposed to putting things in place to make it more difficult, and I think in that 20 respect, there are, I think, a lot of areas of local planning that can just get on and do things as long as they’re given the freedom and given the capacity to do that. MS WALLACE: Do that. Yeah. Larry. 25 MR PIERCE: Just a quick comment to that. While I accept your point, I think what I heard from Alison was that LHDs and PHNs are a mechanism for delivering funding priorities within programs that already exist, and the Commonwealth, in my view, has put the PHNs in that role by diverting the contracts they used to run nationally straight - - - 30 MR KMET: Not all of them. MR PIERCE: Not all of them, and also all that new stuff from the Abbott Government’s ice – National Ice Action Strategy, NIAS, funding. So what – you’re 35 not an ideological apparatus of the state. You are certainly seen as a Commonwealth funder. MR KMET: Yes. And the point I was making was that the document needs to recognise the way that works in regions - - - 40 MR PIERCE: Yes. MR KMET: - - - is different. That’s what I’m saying. I agree with you entirely, Larry. 45


MR PIERCE: Sure. MR KMET: And I think in relation to all of the things that have been said here about funding in terms of short-term contracts and so on, we are subject to that framework, and I certainly won’t be the ….. those frameworks. 5 MS WALLACE: Okay. But I think that goes back to, Alison, your point about the importance of role clarity, irrespective of where you sit in the system as well. PROF RITTER: Yes. 10 MR KMET: Yeah. DR MOORE: I mean, I think in a highly functioning federation of states you would have role clarity. 15 MS WALLACE: Yeah. Yes. Are there other comments? Yes, Mary. DR HARROD: I just want to go to something that Jo said and this gentleman here, and also the short-term funding, and I guess that it’s just to point out that, if you’re 20 going to do planning at the local level, which we need to do, then consumer engagement becomes critically important, which Jo highlighted as well, and that those short funding cycles – like, consumer engagement in the population, this incredibly alienated population from the services which we’ve heard lots and lots of evidence about, is going to be difficult, and it’s going to require time and patience 25 and, obviously, funding, and building that into the funding mechanisms and the planning is going to be – we can’t take it for granted that it’s going to just happen. MS WALLACE: Yeah. Thank you. Are there comments about – yes, sorry. 30 THE COMMISSIONER: Could I just come back to Jo for a second. Jo, you mentioned that there is a draft strategic document, I gather, in train at the moment. DR MITCHELL: Yes. Yes, there is. 35 THE COMMISSIONER: Are you able to tell me – and if you’re not if it’s fine, but are you able to tell me if that’s anticipated to be, you know, and overarching strategic plan for drug and alcohol services in the state? DR MITCHELL: The work that we’ve done around thinking about our strategy is 40 very much focused on New South Wales Health and so the focus is around the area of the prevention and harm minimisation, so the early stage as well as the ways that we want to influence our current services, and then also looking at partnerships into the future. 45 THE COMMISSIONER: Right.


DR MITCHELL: So it is a health-focused document, and part of what we’re wanting to do with that as well, and which I think that we’re doing through our actions, is looking at building the relationships with different actors to look at some of the things that we can do to improve the communication but also to make system changes in those places that we know are priorities for us. So it’s a health document. 5 THE COMMISSIONER: All right. Thank you. MS WALLACE: I do want to move on shortly to, sort of, planning and how that occurs at the local level but are there other comments around how strategic planning 10 could be done better from a national through to State to the local level, other points that people wanted to raise that haven’t been raised so far. Yes. Go on, Michael. DR MOORE: It’s a bit of a broken record. We are a federation of States. We need to know what – in particular, what Victoria and Queensland are doing. 15 MS WALLACE: Yes, in terms of any cross-border issues? DR MOORE: Yes. 20 MS WALLACE: Yes. Yes. So I’ve been making sure that that’s a factor to take into account. MR KELLY: I’d be curious to know where the - - - 25 MS WALLACE: Yes. MR KELLY: - - - people think the responsibility lies for alcohol and other drug strategy that isn’t just health focused at a State level. So we had Larry say earlier what came out of the drug summit was a - - - 30 MS WALLACE: The whole of government, yes. MR KELLY: - - - sort of centralised whole of government response, and we’ve heard Jo say that the strategy that’s currently under development, is it specifically a 35 health document. I just wonder where people think the responsibility lies for the broader planning. MR PIERCE: I think I would go back to the drug summit model in terms of the implementation of that plan that recognised that Health, whilst a major player in 40 clinical and treatment service provision, was not the only player needed to provide a very – a holistic and linked-up response to drug and alcohol problems, because the issue of, you know, stigma and discrimination prevention and harm reduction services, housing, employment, the criminal justice system. And you’ve heard this through your hearings again and again; it has got to be a whole of government 45 considered program with lines of responsibility by various of the line agencies in this


State very clearly articulated with a funding and a planning mechanism that is joined up. MR KELLY: And - - - 5 MS WALLACE: Cate. Sorry, I might go to Cate first and then back to - - - MR KELLY: Yes. Sure. MS HEWETT: Just to compliment Larry’s comment, it also involves FACS. So 10 FACS are identifying a lot of our clients and, you know, FACS is a huge burden to small organisations in the way that they approach safety needs around children and they, you know, fall outside the strategic plan as well as another ..... government that needs to be incorporated. 15 THE COMMISSIONER: Would anyone disagree that this does need to be a whole government approach if there were to be a strategy in place? Would anyone disagree with that? MS HEWETT: No. 20 DR MITCHELL: Could I just mention to that, of course, there is the national structure of the ministerial drug and alcohol forum which is not just from a health perspective and then also the national drug strategy steering committee as well. So at a national level, they are the – that’s the oversight model in terms of this area as a 25 whole. So work on the National Ice Action Strategy, for example, sort of gets fed through to that key organisation as well. I mean, I think from a health perspective for us having the focus on what we’re able to do and our wanting to go forward with the health focused stuff is very important for us, but I’ll also comment too that we do have very strong linkages with our agency partners as well. So that’s, sort of, part of 30 the way that we work, recognising that there’s a shared responsibility. MS WALLACE: All right. Well, I might just have a bit of a go at – sorry, Walter. Apologies. 35 MR KMET: I just wanted to pick up that point Larry started to make about whole of government and you’re making about whole of government. This is exactly where national and State planning needs to take place, and that is how is it that that planning can ensure that you can begin to break down the silos in funding responsibility and provide continuity of care. That planning should, if not should 40 require local service providers to be part of a system, as opposed to work independently. MS WALLACE: Yes. 45


MR KMET: And I think that should be the focus of those plans, not just to say “well, we should all work together”, but actually require people to do things like co-commissioning and be able - - - MS WALLACE: Yes. 5 MR KMET: - - - be able to move funds from different silos of the system to actually make those things happen. So planning should then lead to policy which allows people to go and do these things. 10 MS WALLACE: Yes. MR KMET: And - - - MR PIERCE: Which is why central government oversight is so important. 15 MR KMET: No question, and that’s where some on the local level when you come to data you can say, “Well, actually, I can share the data with the police. In fact, I’m required to share the data with police because I’ve got the government imprimatur to do that. At the moment, and being involved in services reforming Western Sydney 20 for many years, you know, often – often people maintain their silos because they can actually stand behind things like that and say, “Actually, I can’t do that, so I won’t do it”, but actually they never really want to do it. And I think we should require people to actually do things that allow you to breakdown those silos, and that comes from central planning and policy. 25 MS WALLACE: So in terms of what – I’m just going to have a bit of a go at summarising sort of what I’ve heard, sort of, from the conversation round the table around planning at the government level. There’s a very clear message about alignment between what’s happening at the Commonwealth, what’s happening at the 30 State, including across into other jurisdictions, as well as how that lines up to delivery at that local and regional level. A really important point about thinking about planning for the future as well as what you’re building on looking back. The criticality of political leadership and, for New South Wales, having a whole of government whole of system plan for alcohol and other drug services, recognising 35 that Health got work underway to improve the planning of delivery of services within Health but acknowledging that there are many interactions across into other agencies and parts of government as well. Role clarity Alison made a very good point about and making sure that, you know, 40 everyone is very clear about the role that they play in the system and that there’s agreement about that, and particularly thinking, too, about the important role that data plays. So it’s very difficult to plan if you don’t know where those services are at the moment. And Mary made a great point, you know, around, when you’re thinking about planning, engaging people with a lived experience, consumers is 45 really important, and that’s something that will take time and important to take them into account.


I think the end of the conversation is really about how do you make sure you put the appropriate formal governance and other mechanisms in place to get traction on the ground around – so it’s just not a set of principles but it’s about what does implementation look like in reality and how does everyone – how do you make sure that you get that traction on the ground. Anything else? Any final comments people 5 wanted to make? Yes, Mary. DR HARROD: Can I make one final comment about the people that aren’t in the system. 10 MS WALLACE: Yes. DR HARROD: And this goes to the point of, like, a cross-agency approach. And, you know, in what we see in our work is that the branches and the various government stakeholders are really working at counter purposes to each other, you 15 know. So policing very often is a barrier to services. FACS is a barrier to services for people that aren’t in the system, and we really need to keep a lens on the people that aren’t engaging with the system because they’re the people that are most at risk and I feel like they can very easily get left out of these discussions. 20 MS WALLACE: Yes. Thank you. THE COMMISSIONER: When you say “policing”, are you meaning, sort of, the whole criminal justice system and - - - 25 DR HARROD: From top to – so, you know, people stopped outside of needle and syringe programs and - - - THE COMMISSIONER: Yes. 30 DR HARROD: - - - searched for equipment. THE COMMISSIONER: Yes. I see. DR HARROD: You know, people having naloxone taken off them, people who the 35 police are called when they call an ambulance for an overdose. Like, those examples are just - - - THE COMMISSIONER: Yes. 40 DR HARROD: - - - you know, rife. THE COMMISSIONER: Yes. MS WALLACE: All right. Well, I might then shift then on to planning at the local 45 level, and, Stewart and Glen, I thought it would be useful to hear about the work that you’re doing to ..... and your co-commissioning model on the north coast, because


that cuts across two LHDs in the PHN. I’m not sure who’s wanting to make the comments to start with. MR DOWRICK: Well, I think I - - - 5 MS WALLACE: Stewart. Yes. MR DOWRICK: Thanks, Leanne. Look, again, 12 months ago – and I don’t think I’m about to say anything which is new except two LHDs in North Coast, northern New South Wales with the primary health network North Coast agreed to, I guess, 10 look at and use, I think, a commissioning framework eventually, get to that stage, using mental health and drug and alcohol as the initial basis point of that. I guess the aim is for us to map all our services we provide but also bring in the social determinants, also bring in Family and Community, police and other organisations, which they’ve been doing. And I guess we’re – our focus initially will be – and so 15 far it’s been done in good faith – the two – the three boards and the three CEs are all in agreement to where we’re getting to, and building that joint accountability, joint – building those KPIs that we believe are appropriate for – we all share – and I use the word “all”; just not the three health providers, but those external. 20 Between us, I guess, the next 10 years in mental health and drug and alcohol, we’ll at least spent a billion dollars in total, acute and non-acute services, between all of us. But can we utilise those funding differently into the future, and act differently, and think differently, once we identify those key strategic priorities we have? And North Coast does have some challenging community – sort of – a range of issues in drug 25 and alcohol service – and mental health, as well. So it’s getting to that, you know, commissioning point of identifying our focus of – it will initially be on that 16 to 24 age group, starting off with, and see whether we can actually reach agreement on accountability, KPI – but working with all those other partners, and also with the Indigenous AMS world, as well. 30 And, I guess, that’s our aim of operationalising this collective, in a partnership model, that holds us all accountable. We actually all share that responsibility. There is a lot – you know, it doesn’t matter – you can all point the fingers at each other about who’s at fault at where we are today. But can we all agree on that funding 35 model and resourcing differently, and – and actually think differently, and strategically? But yes, we’re well on the path of getting to that point. And hopefully we can sort of embrace that co-commissioning, in a real sense, I think. When the Medicare Locals were set up, there were – the view – the word was, they were going to the commissioning world. I thought, that’s not the space that we want to be, or 40 have been. Least on the North Coast, it hasn’t been successful. And – but we do see this being a model we all share, and have that collective understanding and agreement and accountability. But just not Health; it’s outside of that. It’s with the police, it’s with FACS, it’s with Housing, it’s with all those other 45 agencies. And so far, to date, it’s been well received, well supported, and got some good people behind it so far. But our focus will be initially that 16 to 24 - - -


MS WALLACE: 16 to 24. MR DOWRICK: We think so, initially. That – we think that’s the earliest – best group to start off with, and then we can work – see – go from there. 5 MS WALLACE: And, you commented, across mental health and alcohol - - - MR DOWRICK: Drug and alcohol. MS WALLACE: And drug and alcohol. Yes. Glen, did you want to make some 10 - - - MS JAMES: Yes. MS WALLACE: - - - comments? 15 MS JAMES: I want to also highlight, it’s not just about co-commissioning; it’s about shared investment. And we get a little bit confused about co-commissioning and shared investment. So “co-commissioning” implies that commissioning funds are the sole resources available. However, “shared investment” assumes that 20 partners are directing diverse sources of funding to an agreed strategy in order to best meet the population’s health needs. So, to some extent, the funding available for shared investment will become available through disinvestment in certain programs. Because we – you know – we’re so focused on outputs instead of outcomes. I mean, North Coast Collective is really about outcomes for the rural and regional 25 community, as well. So a partner organisation – so it – the primary leaders are the two LHDs and the PHN. But we have involved FACS; we have Education; we have Corrections; we have police; we have AMSs; we have the Aboriginal Land Councils; we have 30 carers; we have lived experience and care workers. So it’s not just – it is really a shared investment. So a partner organisation may opt for disinvestment, in cases where the funded program conflicts with the collectively – and this is why it’s a North Coast Collective – agreed principles and priorities. For example, duplication or poor return on investment. 35 So shared investment does change from PHN and LHD previous attempts to co-plan. So instead, shared investment is driven by implementation, and planning is only as one stage of the clearly scoped joint process. So at the moment, we’re really deep into looking at systems dynamics. We’ve got the Sax Institute working with us. And 40 we’ve had two really successful co-production and co-planning with all of those range, and a very big input from lived experience and users as well. So – so it requires a cross-sectional partnership at the highest level of the decision-making. So the three CEs have actually signed and really moved on this 45 memorandum of understanding, and really committed funds. There’s actually a lot of trust between partners. And this has taken time. It started off in about


October/November last year, but we’re really moving really quickly now. It’s a willingness to share decision-making – amongst stakeholders, not just the three primary holders of it. There’s mechanism for joint ownership of responsibility, which is really important, 5 which I talked about before. It’s about that cross-jurisdiction stuff, about responsibility, where all partners of this North Coast Collective are shareholders. So there’s common language, goals, principles and strategies, and there’s long-term timeframes. And we all talk about this short-term funding thing; this is looking at the long term, five to 10-year co-investment, sharing and co-commissioning for 10 mental health and AOD services. All that’s underpinned by data, though. And we talk about data, but it is an imperative that we actually have good data and information to inform a thorough understanding of the population health and the services landscape, especially around 15 AOD and mental health issues in the North Coast area, for outcomes. And we’re looking at knowledge of a high return of this intervention, and the willingness to test and evaluate – we talk about “evidence-based”, but we need to be informed by it. We have to be brave, and we have to step outside that – that known norm of what works before. Okay, we can be informed by it, but let’s test it as well. And the 20 coordination. So it’s common language; it’s investment; and it’s co-commissioning, with all the stakeholders. So we have been talking to a whole range, as we’ve been talking to the Commonwealth, been talking to the State, as well as our local partners. 25 The actual response from the community, and from the NGOs, and from consumers, is actually quite amazing. We have people coming up to us, saying, “Can we get involved in this?” This is ground-breaking. This is new. This is absolutely looking at what’s happening in our region. So what happen – because our North Coast PHN 30 is quite good: it goes from Tweed, Byron – one particular couple – right down to Port Macquarie, Lake Cathie, Kempsey; we have Grafton. So everyone’s saying that, you know, they want a say about what’s happening in their areas, and how can we do something differently? It’s very bold, very brave, and it’s that co-investment. 35 THE COMMISSIONER: Do you have a guiding document that you’ve - - - MS JAMES: Sure we do. THE COMMISSIONER: Do we have a copy of that? 40 MS JAMES: Yes, more than happy to. So it’s Shared Investment - - - THE COMMISSIONER: Yes. 45 MS JAMES: Yes. So we’re happy to send that to – yes.


THE COMMISSIONER: That would be great. What’s it called? Shared - - - MS JAMES: It’s Shared Investment for Population - - - THE COMMISSIONER: Yes. 5 MS JAMES: - - - Health on the North Coast. THE COMMISSIONER: Right. Thank you. 10 MS WALLACE: Thank you, Stewart and Glen, for, sort of – because I thought it was useful to kick off with, sort of, that work that’s being done on the North Coast. But, Teresa and Amanda, I wanted to go to you now, to talk about, sort of, how you plan for your alcohol and other drug or drug services in your local health districts. Teresa, we might start with you. Just, sort of, thinking about, sort of, how you take, 15 sort of, the – you know – health priorities, and all the work that you’ve got to do, and the work that you do locally, in terms of planning at the local level. DR ANDERSON: Thank you. Well, I do think it does start at the state level, and I think one of the great strengths – and I know we’ve talked about all of the 20 challenges, but there are some strengths in there – is that New South Wales Health does function as a system: the chief executives get together on a regular basis, a few days a month, where we share what’s happening across the state, share ideas, try to leverage off what each other are doing. And our drug and alcohol and mental health staff meet, on a regular basis, with the ministry, as well. So that helps to inform what 25 we’re doing. And we’ll be talking later about the annual service agreements, but I think that’s a really important part, is that when you look at that document, it says very clearly that we are to follow what happens at a state level. The priorities that are within that, 30 New South Wales Health Priorities, as Jo said, very clearly state that drug and alcohol is a priority. And then, at a district level, our planning is informed by those processes. And we do have a drug and alcohol plan, which we refresh on a regular basis, but 35 that actually sits with a whole range of other plans, because, as I said in my – you know – what’s a priority for me – it’s understanding that drug and alcohol issues do not exist in and of themselves; they are part of a whole range of things. And Stewart was talking about – and Glen – about the social determinants of health: we know that there are a whole range of influences, and someone who has a drug and alcohol 40 problem usually has a whole range of other things. And if you take it out of its context, I think, we have a major problem. So, in our district, we have a district strategic plan, that is refreshed on a regular basis. That’s developed in partnership not only with our board and our executive, 45 but all of our clinicians and, very importantly, our community members. Our PHN representatives give feedback into that. And then that strategic plan, at a district


level, informs, then, our various other plans, so our drug and alcohol plan, our mental health plan. But they all intersect, because of the complexity of the issues that are affecting the populations that we serve. So when we’re looking at our drug and alcohol plan, it intersects with our violence 5 and neglect plan; it influences – it interacts with our maternity and child health plans. And then we have a – and I know it sounds really complex, but it actually works – where we have a particular focus for particular communities that we have. So, for example, in Redfern, Waterloo, Green Square, etcetera, we have plans that are multi-sectorial, that have all of our government agencies involved. 10 And a key part of that is what we call Healthy Strong Communities, which intersects with our mental health, drug and alcohol, homelessness services, but has everyone at the table: all of our non-government agencies; people with a lived experience, both those who are peer workers but also people from the community. And that helps to 15 inform the way in which we do our business. So to me, those intersection of those plans is really important. I think it would be really problematic for me, as a chief executive, if I saw a drug and alcohol plan just sit to the side. It has to intersect with all of those things, so that we make sure we’re 20 constantly looking at who’s at the table, and making sure that that co-design really is informing the way in which I, as a chief executive, prioritise the services across the district. And I need to be really clear: I don’t do that; it’s done in consultation with all of 25 those various partners, and, very importantly, the PHN. So I’m on the board of the PHN. We have significant consultations that we do as a PHN together. We prioritise the way in which we do our work together. And, as I said, the PHN has evolved in the way that the district is doing its planning. So those intersections are really important. 30 But very importantly for the planning is the doing. And our board has been very clear: we can’t have a plan unless we report to the board on our progress. So we have to regularly report on our progress, and we also report to the community, at our Annual General Meeting, and a whole range of other strategies about how we’re 35 progressing, because we are being held – and we should be held – to account to the community that we serve. So that’s a bit of a summary. MS WALLACE: Thanks, Teresa. Michael, I’ll come back to you, but Amanda, from South West Sydney’s perspective, in terms of planning - - - 40 MS LARKIN: Yes. MS WALLACE: Yes. 45 MS LARKIN: So I’m not going to repeat what Teresa spoke about in relation to that relationship with the State. The State very clearly sets a number of clear


priorities; they’re articulated, as Teresa said, in the SLA. And I think we just need to understand – because there were some points earlier about the mechanics of government, and what’s been set up. The districts were established in 2011, to ensure that local contact and engagement with their local communities. And the South West community is big: there’s over a million people in South West. It goes 5 from Marulan, pretty much, to Bankstown. So this is a big community. But how they’re structured, and how they relate, at a community level, I think, is really critical. And we’ve been able to do that, I think, in a number of ways, because you see clinicians engaged in the board now; there are clinical councils; there’s a 10 whole range of engagement processes, together with the community. And, Teresa, you’ve got that also. So, from my point of view, that link is critical. And I think, for us, though, in South West, there is an advantage. The PHN boundaries were, and still are, the South Western Sydney boundaries. So the 15 relationship between those two very important parties has had a long and a deep history, in terms of how they work together. And, picking up on what Walter said, yes, it is about relationships, but it’s also about, you know, how those government mechanisms actually work. So for us, I would argue that they work strongly, and are very linked together. So that’s the first point, I think. 20 So, from a planning point of view, we are very much linked to the State, in terms of the State’s priorities, clearly articulated in the SLA; and we’ll talk about that in a little bit. We have very – also – a very clear strategic plan, and a clinical services plan. Because, I think, when you talk about drug – drug health services, I think, 25 you’ve got to think of three components, and I don’t know whether we’ve articulate that clearly enough or just assumed it. There’s all the community-based services that people interface with on a regular basis who them also interface with the other agencies, so this is not done kind of like in isolation – Justice, Family and Community Services, either on a program basis or on a clinical basis. Then there is 30 all the work and the work with the PHN and the services that we do there. Then there’s also all the planning and considerable work that’s done in the NGO sector which is significant in South West, and then there is the tertiary services, so people come into the emergency departments. They come in and access ICU. They interface with maternity services. 35 So what’s really critical when we think about planning is how all of those sectors actually work together to deliver care for the community, and to me, in my district, that interface and those linkages are strong. I’m not saying they all can’t be better. There’s absolutely opportunities for us to do it better, especially in the emergency 40 departments when we see people come in extremely unwell. We could do that better. But it’s how those three – so when we’re thinking about planning, it’s all of those elements together that deliver comprehensive care for the community. And then the other layer that we kind of haven’t talked about, and Cathryn is sitting down at that end of the tower and perhaps is a silent voice, but capital planning both in terms of, 45 yes, the new bill work but also the services that exist in the community and how we actually do capital planning and provide those services in the community and support


the NGOs where we can is also a critical element. So all of those layers need to be considered when we’re thinking about how we deliver care. MS WALLACE: Michael, did you want to make any comments at this point in terms of that planning at the local level, particularly LHD, PHN? 5 DR MOORE: Well, what I would say is New South Wales were lucky in that the PHNs and the LHDs have congruent boundaries and that’s not always the case everywhere. Particularly in Victoria they have problems with that. 10 MS WALLACE: Yes. DR MOORE: And that’s a big advantage for us. MS WALLACE: Yes. 15 DR MOORE: And what it means is that it’s relatively easy for us to jointly plan with our LHDs, and we do. So Theresa has already said that they already involve us in their planning, and similarly we involve the LHDs integrally in our planning. You know, it’s just part of how we – we – our normal business is to involve each other 20 because we’re both key partners; however, when you start looking at the multi-sectoral operation, it’s more difficult. There was a kind of special magic moment in time where FACS had the same region as the Medicare local – as the LHD, and we did a joint child and family plan because it was possible to do it. Now that would be really hard because they don’t have the same region. So, I mean, I think in general 25 terms if you’re looking for cross collaboration, you want to make sure that the administration districts are congruent. MS WALLACE: Yes. 30 DR MOORE: Because with LHDs and PHNs in New South Wales, we have that happy circumstance and it’s actually really good because it means, you know, we have really good relationships with the people. But, look, the other quick point I will just say in terms of planning, both LHDs and PHNs – PHNs perhaps more than LHDs – administer contracts in drug and alcohol that they didn’t necessarily plan for, 35 so we have about 50 per cent of our contracts – got – I will have to think of a diplomatic way of saying his. MR PIERCE: Novated to you. 40 DR MOORE: Novated, yes. They took a wheelbarrow and said, “Here you are.” So, yes – so we didn’t actually plan for those contracts. We were given them. And I understand the LHD has many similar contracts that they administer on behalf of the New South Wales Ministry of Health. 45 MS WALLACE: Sorry, Amanda, did you want to make another comment?


MS LARKIN: Just one – only one. I think one of the other critical roles between the PHN and the LHDs, and it has been done for a number of years, but I can say in the South West we’ve done it in a much more integrated way, is we write a population health needs assessment which gives an incredibly deep understanding of the health issues in the broad context, not the narrow context of health – in the broad 5 context impacting on a community. And then as a supplementary to that we also did, in preparation for some of the commissioning work, a coordinated drug and alcohol needs assessment. So you get a really good understanding about what your issues are, where you direct resources, how you can co-commission, how you can actually work with your NGOs, etcetera. So to me there has been some foundational work 10 that has really much, I think, informed how we’ve gone forward with drug and alcohol services. DR MOORE: I think the joint planning explained that PHN and LHDs has been one of the great successes of that. 15 MS LARKIN: One of the great successes. Very strong. MS WALLACE: I want to – yes, thank you. So you sort of hear about sort of how the LHD, PHN planning works, but I’m particularly clear to hear from the NGOs and 20 what it looks like for them on the ground in terms of local planning. Norm, perhaps if I start with you. MR HENDERSON: Yes. Out in the back country where I spend most of my time, I’m talking ..... Bourke ..... all that area, the planning is not as – I understand the 25 complexities that you’re talking about there and all the multi-sectorial plans and all this type of thing, but out where I am, this stuff is almost non-existent. Again, you’ve got logistical problems out in those areas as well of getting everyone together. Just as an example, like, I’m here today. Last week I was in Bourke ..... and Lightning Ridge and then the week before that I was in Dubbo. So you’ve got a 30 lot of complex problems getting all the people together. And we’re talking about most probably the most marginalised and stigmatised mob of people going, predominately Aboriginal populations. There’s a lot of historical complexities with getting people together – getting 35 communities together with LHDs in the way they see drug and alcohol and mental health services. So there’s a lot of breakdown you’ve got to do, and what I’ve found out there is that especially with the PHN commissioning – some of the PHN commissioning, we tend to get told what sort of services we’re going to tender for, and then we have to start tendering for them and then changing how – and trying to 40 feed that back up, so I believe out in specifically those areas, there needs to be a ground up. It needs to come from the local community back up to big bodies like NADA, the AH&MRC, and then they can do all the sectorial stuff. They can do all the talking with the government bodies. But I’m in charge of three projects: one in Wagga, one in Bourke and one in ..... Parkes. 45


Now, what I do in ..... Parkesis completely different to what goes in Wagga, is completely different again to what goes on in Bourke. And out of all that, especially with Aboriginal communities, you’ve got to deal with not only the whole maybe, maybe the whole community. So you can’t just pluck one person out and fix their problems, like – and that seems to be what gets put down on us. It’s like, “No. No, 5 it needs to be done differently.” And people and looking at it and listening but there’s not a great deal of change coming from the top. And, I mean, you also – on top of that you’ve go services for women and especially women with kids, so you’ve got FACS involves and then you’ve got Justice and all of that, and they don’t – historically they’ve never talked to each other and they’re still having problems 10 talking to one another. So it is a big problem out and – but people are actually listening, but it’s very hard. MS WALLACE: Thanks, Norm. Cate, did you want to make some comments around sort of what makes planning in that local level work best, or even on the flip 15 side, what the barriers are, I suppose? MS HEWETT: What the barriers are. State-wide service is a barrier. MS WALLACE: Yes. 20 MS HEWETT: And while it’s really refreshing to hear what’s happening in the Northern Rivers, I would love to be at that table because I get a stack of clients from the Northern Rivers. You have a great detox centre that refer to us. So when we’re restricted to PHN and LHDs as a state-wide service, that’s a huge barrier. So we’re 25 no at tables where really important conversations are being had about a population of women that we serve. So, first and foremost, PHNs, we were great in getting a fabulous grant from them to be delivered to our area for residential rehab. We don’t have a detox service in our – in – on the Central Coast that will see a woman after 11 weeks. 30 I think they might have just extended it to 20. So we needed a detox service for pregnant women to provide a continuity of care and enhancement to that, but because the current female-based one wasn’t in our PHN, it wasn’t able to tender into that area. So there are difficulties with the modelling of PHN funding that you have to – 35 we’ve been told, as has Jarrah House, that you have to be within that area to put in for tendering grants. Being a state-wide service, our clients are coming from your area but we can’t have that conversation with you. It’s very difficult. So – and also another comment about the devolution of funding from the state to the local health district. I felt so sorry for he local health districts when they were burdened with our 40 state-wide service. How can they be really interested in the intricacies of our service delivery when, you know, it’s a small percentage of their population that we’re providing a treatment to? How can we expect them to be actively engaged with us? So in different areas, there’s brilliant models but, again, it’s centralised to the district. I have no mechanism to channel up unmet need. I detail it in my annual report every 45 year about the number of requests for treatment, the number of assessments versus the number of admissions and the fabulous outcomes that are achieved, but I have no


mechanism to say, “Hey, will you sit down with me and talk with me about my unmet need?” because this is emerging now as a result, in particular, our pregnant women, increased pregnancies, unplanned pregnancies, due to ice and amphetamine-type substances. Who do I talk to about that? 5 A local area, I can pick up the phone and that’s – that’s fabulous, and it’s not their entire population. It’s a small percentage. So I would harp on and on and on about that until - - - THE COMMISSIONER: Who would you like to talk to? 10 MS HEWETT: State. So we had a great model for me back then. I was around when we had direct contacts to State, and so they knew our program. I had a person that I could call. I had a person that read my report. I don’t even know if anyone reads my reports that I – that I send through to our Local Health District. I send it 15 through and that’s it. As long as it’s sent in, there’s no more communication about that. Now, that’s not – that’s my experience. I don’t know if it’s everyone’s across the state but – so I don’t get any feedback. There’s no incentive to provide huge amounts of information because the energy that you put into that isn’t rewarded or, you know, doesn’t invite a conversation around it, so why bother. So I do as much 20 as I can, but then it stops. There’s no conversation. MS WALLACE: Okay. You make a great point about sort of, you know, where you’re providing the state-wide service, how that intersects with the planning at the local level a well. Gerard, I’m just going to see if you’ve got any further comments 25 to make. Then I know Theresa wants to make some additional comments as well. MR BYRNE: Not really. I think Cate has covered everything - - - MS WALLACE: Yeah. 30 MR BYRNE: - - - you know, in relation to that clash between, you know, a NGO, the state-wide remit due to funding being hosted at the local level. MS WALLACE: Yes. 35 MR BYRNE: And that is nothing about the people that we work with because the people within the context of those LHDs are good people who work with us to make the system work. 40 MS WALLACE: Yes. MR BYRNE: But they also see the clash within it as well. On top of that is, you know, coming off the back of the grant management improvement process that New South Wales Health ran a few years ago, we were expecting to see, you know, a 45 reduction in the burden of compliance, and today what we see is actually an increase in that burden, you know, to the point where, I don’t know, like paperwork becomes


more important than people. And, you know, when we start to diverse – to divert, you know, resources into compliance, then, you know – and we’re not getting proper resource for that, and there’s going to be – there’s going to be some give somewhere, and a give always ends up, unfortunately, at the service delivery level. So, yeah, I don’t have anything more to add on that clash. 5 MS WALLACE: Yeah. And - - - THE COMMISSIONER: Gerard, what was supposed to be streamlined that, in fact, hasn’t been streamlined but has become more burdensome? 10 MR BYRNE: Reporting processes. THE COMMISSIONER: Yes. 15 MR BYRNE: Grant management processes and compliance processes around those reports. I think it would be great if they moved to a – like most businesses these days, moved to a preferred provided status and, you know, you got your preferred provider status – it was relevant for five years, for argument’s sake – and then an organisation went in again, without constantly having to, you know, report the same 20 information over and over again. MS WALLACE: We’ll certainly come back to that again when we talk about the way NGOs are funded as well but, yeah, great points to make. I’m going to come back to Theresa. But Mary. 25 DR HARROD: Yeah. I mean, I just want to say thank you for being at the table, and I guess the reason I’m here is in recognition that the consumer voice is important in this, but as an NGO we’re funded primarily for work in hep C and BBVs, and a fairly small part of our funding is actually for this type of work, and it’s really only 30 myself that gets funded for it. And in terms of, like, the PHNs and the commissioning, I have to sort of single out CESPHN, in particular, for, like, ongoing engagement. But we certainly have had a lot of requests for engagement for PHNs around the state and it’s – we do our best, but without any overall kind of – you know, similar problems to yours. We don’t have any way to engage, in a broad 35 sense, with LHDs and PHNs and, you know, not that we’re necessarily – you know, there is no other agency to do it. We’re not necessarily the people that – you know, there is no broader consumer organisation. We don’t cover alcohol and other drugs, so there’s kind of no structured – and I think there is a real value in having a structured consumer voice but there’s just no mechanism to provide it. 40 MS WALLACE: Theresa, did you want to make some comment? DR ANDERSON: Yeah, two things. One is in relation to particular communities, like our Aboriginal and Torres Strait Islander community, we have a large 45 community within Sydney and the AMS and the land council provide us with great leadership in relation to that, and one of the things with our AMS, it goes across local


health district boundaries, so we’ve had now an agreement in place for a good eight years between Northern Sydney, South Eastern Sydney, St Vincent’s, Sydney Local Health District and the Children’s Hospital, particularly around the social determinants of health, but identifying our priorities together and, again, we have a regular partnership meeting. 5 And I do think that that model for our community has worked really well, making sure that we’ve got strong voices about where services should be provided, so we provide a lot of drug and alcohol services within the AMS. We also fund the AMS. So we’ve been able to decrease duplication, increase our reach, by having that 10 process. And then we engage various government agencies, as appropriate, and other NGOs that are associated with the community. And I think those different approaches – Norm talked about how different communities have different priorities, and I think we need to make sure that it isn’t a one size fits all for every community. 15 The second thing is around NGOs, and I’m fortunate, in our district, we do host quite a number of state NGOs, and I have to say we work really closely with the ministry and have state people at those conversations, and that certainly does help us so that we’re all aligned and there’s no contradictory information, and we do have conversations with our fellow LHDs in relation to that. We’re fortunate we do have 20 an NGO manager who has a very close relationship with all of the NGOs that we fund, but also the NGOs that we don’t only fund but we work with closely and co-design. One of the things that was really missing for us is having regular face-to-face forums at a whole which we’ve been implementing, and that’s certainly improved the communication. 25 So it’s not only with those staff on a day-to-day basis that are working with NGOs but, very importantly, with the executive of the district so that, you know, you can hear more directly yourself rather than just at all the different planning meetings. And for us that also includes our cultural leadership groups because in our district we 30 have 145 community languages. We have a very large challenge in relation to the various groups that we have and making sure that the leaders within those communities are getting a voice as well. For me, it’s always a learning experience. I sort of think that somethings are covered and then I discover that we’re just not communicating as well as we could with particular parts of our community. 35 And I think, you know, again, it’s about how do we learn from everyone about better ways of doing things, and I think hearing across the state what everyone is doing is really important for all of us. 40 MS WALLACE: I might just go – Amanda, I’ll come back to you. I’ll go to Dan and see – is there anything else on – this will probably – this topic will flow over a bit into our next discussion and the one this afternoon, and I’m just a bit conscious of our time. And I imagine Jo would like to make some comments as well. 45 DR MITCHELL: Yeah. Look, the comment that I would like to make in terms of if there are sort of some of those communication gaps that are happening locally that,


of course, the ministry is a place that you can come to, and certainly through NADA as well – your connection with NADA about helping to sort through some of those issues if and when they arise. So I suppose it’s just saying that that pathway is there. MS WALLACE: Thanks, Jo. Amanda - - - 5 MS LARKIN: And, look, just very quickly, Theresa, I know that you do – and so do I – we run state-wide services, both in terms of state-wide services within our – within Health but also with some of the NGOs, and I think there is a really clear responsibility to ensure that, as an LHD, we represent not only the issues that are 10 consistent within the LHD itself but those that are in other areas. So, for example, we run the State Refugee Service. There is a very high concentration in South-Western, but a very high concentration also in Western Sydney in terms of service delivery and the regional areas. The planning and delivery of those services requires consultation so that communication structures that are not set up are really important 15 to set up the agency has a vehicle to raise issues or concerns with the Ministry, whether it be around service delivery or their gaps or whatever. So I think we’re very clearly charged with that responsibility and I know that, you know, we put quite a lot of effort in to ensure that those channels of communication are well established. Not saying there can’t be gaps though. 20 MS WALLACE: Yes. Cate? MS HEWETT: Just in response, Jo, the Ministry is fabulous. You’re really, really nice people, but getting that – and I always can. I know that I can – there are people 25 there that I can send an email to and make a call to, but it gets back to Alison’s point of roles – of clearly defined roles and pathways. My relationship is with the LHD and then is it with Larry at NADA as well and then with the Ministry. I’m running a service. I just need an agreed pathway that perhaps isn’t driven by personality and fabulous people in the department but is a concrete path of this is who I report to and 30 just one stop, because I can’t be rallying my troops with conversations at those three different levels, and then federal as well. I just need to deliver the treatment. MS LARKIN: Yes, noted. 35 MS HEWETT: Yes. MS WALLACE: And that’s probably a great point to - - - THE COMMISSIONER: Yes. 40 MS WALLACE: - - - finish off on. THE COMMISSIONER: Yes. 45 MS WALLACE: And, again, I’ll have a bit of a go at, sort of, summarising the issues and, as I mentioned, I think this issue about how planning and delivery of


services works at the local level will continue to be part of the conversation today as we go. But I’ve certainly heard from Stewart and Glen, you know, a great example of not just co-commissioning, as Glen pointed out, but shared investment and having that very strong, very, you know, whole of system type approach thinking beyond just what Health LHDs and PHNs were doing but engaging all of the people in the 5 process building on trust, obviously, has been quite important. And also, I think, some of those formal mechanisms you’ve put in place to make sure, and we heard that, the importance of accountability. You know, whether you have an MOU or you’re reporting to your board, as Teresa talked about, is going to be really important. 10 Some mirroring of the comments about State-wide, about the importance of having planning underpinned by data, and a number of people talked about the importance of adjusting your planning for place, so Teresa talked about that. Norm, you really highlighted that, perhaps, strongly that, you know, it is really about thinking about 15 how it’s delivered at the local level, and particularly in rural and regional areas, the challenges that just the distance and the whole range of things that you’re doing presents for that. There was also, I think, highlighted in the back end of the conversation about how does that operate from a State-wide service. Obviously having those clear pathways and roles and responsibilities came up as well. Any 20 further comments people want to make before we break for morning tea? Alison. PROF RITTER: If it’s working almost as well as it’s been described in this last conversation between the LHDs and the PHNs, do we need to have a State-based review, or – I’m really struck by a sense that it’s – notwithstanding that there are bits 25 and pieces and consumers aren’t funded and we could do things better, I’m really struck that this conversation has been quite optimistic about the LHDs and the PHNs, and notwithstanding State-wide, as the central local planning unit for the population of New South Wales, and I suppose that makes me reflect on, well, where are the problems that are well documented in here? 30 MS WALLACE: Yes. MR PIERCE: I can answer that. 35 MS WALLACE: I’m going to Michael, Larry, then Walter. DR MOORE: So you’ve asked the question, so I guess we have to answer it. Look, I think in terms of planning with the PHNs and LHDs, that’s pretty good. 40 PROF RITTER: Yes. DR MOORE: In terms of planning with other sectors, not so good, and I mentioned the fact that we don’t share common regional boundaries. 45 MS WALLACE: Yes.


DR MOORE: And when FACS shared a common boundary with us, suddenly it became really easy to plan with them. MS WALLACE: Yes. Yes. Okay. 5 DR MOORE: The other point is that both LHDs and PHNs, although we can plan together and we can dream together, there’s constraints that we face. So PHNs, up until now, half of our contracts have been given to us to administer. LHDs, I don’t know what proportion of your contracts. So, you know, the amount of wiggle room that we have is not big. So we can have these great joint dreams, but in terms of 10 doing something about it, our hands are tied by North Sydney and by Canberra. MR PIERCE: Indeed, and it’ll go - - - DR MOORE: And I think that’s your point. 15 MS WALLACE: Yes. DR MOORE: Planning should be actually breaking the ties and letting you do stuff. 20 MR PIERCE: And I go back to Gerard’s point on that is that the contracts that NGOs hold that provide specialist drug and alcohol services are so prescriptive and so historically focused that they don’t allow the room for the more creative planning and moving forward visioning that Gerard was mentioning before in terms of planning for the future. 25 MS WALLACE: Yes. Yes. Walter? MR KMET: I think all that’s correct and I think all of the reflections on the good work happening between PHNs and LHDs is there. I think the novated contracted 30 which you mentioned before is an interesting one, and I remember there was a word used around those ones that they were going to be melting ice cubes. There’s no point providing funding to a system where the – all the regulations around that funding are so strict that all you become as a PHN, as an example, is a program manager. 35 UNIDENTIFIED FEMALE: Contract manager. MS JAMES: Contact manager. 40 MR KMET: Contract manager. I mean, you need to reduce – as I said earlier, you need to reduce the paperwork or the rigour – if rigour is the right word – around all of those structures and allowed then for that money to go into the system, as is planned. The other thing, of course, is that – and before I left Western Sydney I was the chair of the Western Sydney Service Delivery Reform Group, which had all of 45 the agencies, FACS, police and all those agencies at the table. There were two things I’d say; one is, of course, I think there needed to be a freeing up of regulations so


that people could share information who worked in the co-commission, but the other thing is there’s a huge amount of change management that’s required at the local level for people to actually work together because they’ve worked in silos all their lives. 5 UNIDENTIFIED MALE: That’s right. MR KMET: So, for example, you know, vulnerable families which is a particular area of focus that we were looking at, we were looking at people, you know, care coordinators, other people who we put in the system, and there was kind of this 10 almost industrial relations argument as to who they reported to, you know. But that’s the old system. The old system of who you report to and the structure is the old system. Bureaucracy, governments need to get their head around it. These new people that work in the system actually may not – may work as part of a co-commission environment not within a structure. And we – it took us 18 months to 15 get a speech pathologist on the ground in that particular issue and it had all to do with territory grounds, regulations, frameworks, you name it. And in the end, vulnerable families were what we were there to do. And in addition to that, I should say, there was some agencies, and I won’t mention 20 names, that – where the local people saw real benefit to doing that, but their hierarchy, you know, as big as they were, couldn’t even contribute $30,000 for regional planning. I mean, it was, I was gobsmacked with some of the central agencies. We had, dare I say, DPC who had sponsored that service delivery reform element moving out of the space. They moved out of it and they said, “Well, we 25 don’t need to do that any more.” Well, if you don’t invest in change, if you don’t invest in these structures, they will not happen. MR PIERCE: Sorry, I have to say this is not the State-wide picture of how good the relationship between PHNs and LHDs are, because we get a lot of feedback from our 30 members that say there’s not as - - - UNIDENTIFIED FEMALE: I was just going to say that. So there was - - - DR MOORE: It’s not as ..... 35 MR PIERCE: So you might have picked the two – you’ve picked the three groups where they - - - DR MOORE: ..... exactly right. 40 MS WALLACE: There is a very, sorry, I’m - - - DR MOORE: There’s always variations. 45 MS WALLACE: Yes. There’s a variation. Yes. So I’m going to go Stewart and then I am going - - -


MR DOWRICK: So I’m going to – yes ..... relationship was not as strong as it has become. MS WALLACE: Yes. 5 MR DOWRICK: So I’m not going to gild the lily. MS WALLACE: Yes. MR DOWRICK: Then the Medicare local started and then it morphed in to the 10 PHN. We’ve all through a transition, which is great. MS WALLACE: Yes. Yes. MR DOWRICK: So we’ve gone through a different lifestyle ..... world now. But 15 just with the PHN, something which, I guess, is – and Amanda, Teresa and I started CE world together at the same time back in January 2011, so we’ve all started the three of us. I guess something that we’ve identified and learnt was the fact that, in the PHN world, you know, that, you know, their bucket of money is actually quite small compared to what the LHDs have access to. 20 MS WALLACE: Yes. MR DOWRICK: And also the fact that the ability of them to influence the most important provider here is the primary care space practitioner varies as well. So 25 we’ve got to – there’s a reality of there of funding the influence and the ability of the PHN or us to work with the GPs. You have a different engagement ..... with the PHNs with us as well, and on the North Coast collective that will be so importance that we sort of have that by and from the primary care providers who are separate, generally autonomous to us and these guys. So that’s just a fact of life. We’ve got to 30 somehow work it through the federator model to deal with. So I just want to, you know - - - MS WALLACE: Yes. 35 MR DOWRICK: It’s been a journey; still more to go, but - - - MS WALLACE: Yes. MR DOWRICK: There’s a group of people, not here in the room, which is the 40 primary care practitioners who sit outside of this. MS WALLACE: Yes. MS LARKIN: Can I – just one last point is around when we’re looking at those 45 novated, and, of course, you know, we have got a lot of those novated programs, and round the North Coast collective we’re asking them to disinvest in that but, you


know, there’s people who just want to hold on to those programs and that’s very difficult and that’s one of the biggest challenges that we have outside of the LHD, and there’s also guidelines around these programs as well. So we need to look at how do we disinvest and then reinvest. That’s important. 5 MS WALLACE: So it’s reinforcing, Walter, your point about the – sort of, the rules and regulations that sit around it, yes. MR KMET: And political issues. 10 MS WALLACE: And political issues, yes. MR KMET: Political issues, State-wide services. I mean - - - MS WALLACE: Yes. Alison, thank you for asking the question. Obviously ..... 15 PROF RITTER: ..... MS WALLACE: But, yes, in the follow-up conversation, so, yes, certainly hearing the message about there’s other things that get in the way, albeit that it’s not 20 necessarily consistent across the State either. PROF RITTER: No, no, it’s not. MS WALLACE: Yes. 25 PROF RITTER: No. MS WALLACE: So we are going to have a short break now for – it’s almost lunch but it is going to be morning tea and then we’re going to come back at – so probably 30 10, 15 minutes for morning tea and then we’re going to come back and look at particularly around the drug and alcohol service planning model. THE COMMISSIONER: Thank you, Leanne. 35 MS WALLACE: Thank you. ADJOURNED [12.06 pm] 40 RESUMED [12.24 pm] MS WALLACE: Welcome back. Welcome back, everybody. Welcome back, 45 everybody. There were lots of important side convictions in the break, which is terrific. We’re going to move, now, to – still within the broader topic of improving


the planning of alcohol and drug services, but to talk specifically about the drug and alcohol service planning model as a tool to assist planning, and recognising it is a tool, and it’s one part of the way forward. Alison, I was wondering if you, given your experience - - - 5 PROF RITTER: Sure. MS WALLACE: - - - and involvement in this area, if you wouldn’t mind making some introductory remarks about the DASP and its – you know – how it might be used. And then I might then go to Jo and probably Elizabeth, in terms of how it’s 10 then, in a practical sense, used in the planning of services. So, Alison. PROF RITTER: Sure. So, previously known as the DACCAP, Drug And Alcohol Clinical Care And Prevention, now known as the DASP or the DASPM, the Drug and Alcohol Services Planning Model, developed a number of years ago, under a 15 cost-shared arrangement between the then IGCD, the Inter-Governmental Committee on Drugs, and the New South Wales Ministry of Health. So it was a cost-shared program that the New South Wales Ministry actually invested a considerable amount in. 20 The original goal was to have a national planning tool that would specify the types of treatment and the amount of funds that would be required to provide that treatment, agnostic to who the provider or providers might be, whether that’s an HHS, an LHD, an NGO or a private hospital. So the model predicts the number of treatment places by drug type, five drug types; by level of severity, mild, moderate and severe; 25 across residential and non-residential treatment types, withdrawal, counselling, brief intervention, residential rehabilitation, etcetera; and – yes – and it predicts the workforce that’s required, the FTE, the number of beds, and the costs associated with it. 30 It was finished in 2014 – sorry; I didn’t prep for this – finished in around 2014, and then was forwarded back to the IGCD, which I think was about to become the NDSC, for release. The – it was not agreed to be released. The grave concern was that the model fundamentally predicts a doubling of resources that would be required to meet demand – reminding people that demand in the model represents 35 per cent 35 of people who meet diagnostic criteria. So this is not a ambit claim kind of model; this model already takes out everyone who spontaneously remits, everyone who doesn’t want treatment. So we’re only treating 35 per cent of people who meet diagnostic criteria, and it still predicts a doubling of treatment resources. 40 It was not released at that time, and remained out of the public domain until late 2017, when an FOI was made by Rebekha Sharkie in the Federal Senate, and as a result it became publicly released. Health departments were all provided with a copy of the original model. I’ve continued to work with it, and have done a number of pieces of work very recently, not just the piece of work that you’ve seen here, but 45 I’ve also done work with the Northern Territory Government and with the Queensland Government using the model.


The few things I would say about it are that it’s got loads of errors and bugs; it has a particular problem around amphetamines; the treatment rate is not right; and it was populated for powder amphetamine, not populated for crystal methamphetamine. The epidemiology is very outdated – that is, the population prevalence. The treatment packages are unwieldy. The entire premise of the model relies on a notion 5 of diagnosis, which is arguably misplaced in drug and alcohol treatment planning. The reason why it was built the way it was built was because it was premised on MHCCPP, the Mental Health Clinical Care Prevention Program. While I make the joke, we’re not going to do a forensic – so - - - 10 UNIDENTIFIED MALE: Sadly. PROF RITTER: What’s interesting about MHCCPP is that that has actually now been taken up nationally. A contract has been awarded to the – awarded to the 15 University of Queensland, and it is now the National Mental Health Services Planning Framework, and mental health services across Australia are using this model, and the – it’s national, and it’s centralised, with the capacity and the resources located within the University of Queensland team, that are funded by the Commonwealth to update it, to develop it, and to deliver tailored versions of it to 20 State, Territory and local, LHD/PHN-type players. So there is the possibility that DASP could follow a similar path as the National Mental Health Services Planning Framework. However – so I’ve done some work considering that as an option; I can say more about whether that might be a good 25 idea or not, and how we move forward. The thing that I think is really important is that this is a really powerful tool, if it’s populated appropriately. And the key issue is that as long as it relies on a diagnostic criteria, it will be the same nationally, across the nation, because we only have one source for diagnosis – 30 epidemiological source for diagnosis. If we move it from a diagnostic model to a consumption model, we have significant local variation in consumption rates, through the household survey and other local data, and it could therefore be used to produce different estimates for local areas – LHDs, PHNs, whatever. At the moment, it’s limited in its capacity to do that, because the epidemiology is national 35 rather than local. I’ll stop there; that’s probably more than enough. THE COMMISSIONER: Alison, can I just ask you, when it was initially kept – it wasn’t made public; it was kept – kept from the public domain, are you suggesting that the reason for that was because the doubling that it seemed to predict in terms of 40 required services to meet the need was embarrassing to government? PROF RITTER: I should have remembered that this is being recorded. My perception at the time, not having participated in the discussions, was that there were concerns about the implications of the results of the model in the public domain. 45 THE COMMISSIONER: Right.


MR PIERCE: Dan, I had feedback at the same – because I’ve been around a while, and I was very interested in the first IGCD exposure around this, and the results, as you’ve said, saying that drug budgets were only about 50 per cent of what they ought to be. And from officers involved in IGCD at the time, it was made clear to me that it was State Health and Treasury people who wanted it shut down, because 5 Queensland wasn’t going to – and I don’t mind being on the public record – Queensland wasn’t going to admit that it was only funding less than half of what it needed to have out there. And the problem – and that’s the problem. THE COMMISSIONER: Yes. 10 PROF RITTER: Perhaps the important principle is not trying to understand what happened in the meetings; the important principle is, the model was not critiqued on the basis of its technical details - - - 15 MR PIERCE: Yes, yes. PROF RITTER: - - - or its capacity to be a useful tool in assisting planning for alcohol and drug treatment. 20 MS WALLACE: And that’s – I mean, while we’re talking about the DASP – that’s the intention behind this conversation about what are the appropriate tools to use for, you know, the best sort of planning around drug and alcohol treatment. Jo, I might just, sort of, perhaps – Jo or Elizabeth; I’m not sure who’s the best placed to, perhaps, comment on this – but just for you to talk about how New South Wales 25 Health uses DASP and other, sort of, associated sets of information or planning models to assist with the – with the planning for services. DR MITCHELL: I’m able to comment on the last three years. 30 MS WALLACE: Yes. DR MITCHELL: And so we have used DASP in the build-up for our current service level agreement, and it’s been helpful in showing us some things. 35 MS WALLACE: Yes. DR MITCHELL: We’ve also used other information to help, sort of, guide what we’ve put into the service level agreements. And so what the DASP has told us, in New South Wales, when we looked at it most recently, was – it sort of – it reinforces 40 the comment I made earlier on, around – that the majority focus is around alcohol. So I think it sort of looked around 48 per cent. But it also, sort of, reinforced the notion of unmet need, which again is been a – has been a strong – a strong theme here as well. There were sort of some differences in unmet need for different types of treatment. So from withdrawal management, which was lower, and rehab day 45 programs higher, but all showing unmet need and also interestingly in terms of withdrawal management, what it showed is that there was more in the hospital


setting, which, again, we know unless in the residential and ambulatory withdrawal management, which we know is actually the place that we would be wanting to shift. MS WALLACE: By more – sorry. Just to clarify for the record, so by more, you mean more unmet need in the hospital setting, or the other way around. 5 DR MITCHELL: No. More unmet need in those others. So - - - MS WALLACE: ..... 10 DR MITCHELL: I think that sort of it has given us some information, which, again, sort of reinforces clinical experience as well as, yes, showing us some of those places. Interestingly, too, as it – because I think that the key point here is that that – because we’ve heard about the rural regional as well, and so we did look at it from a rural regional perspective, and there’s unmet need in both rural and metro areas as 15 well. So we have used that information as one of the first places to look, and we’ve used that information to facilitate a discussion with chief executives about whether that accords with the experience from the local health district perspective, but we’ve also used other information as well. So, you know, particularly, we’ve look at things like that service utilisation and how that compares across the state as well so – and 20 patient characteristics, etcetera. So I think that it’s useful as one input, but it’s not the only input, and one of the things that we’re putting a lot of effort into at the moment is around data and improving our data capabilities as well as looking at being able to more readily 25 increase our data analytics so that we can reflect on that data, and so one of the key things that we’re – we think is very important in terms of moving forward around planning for AOD services is the newly established linked records which we call AOD Outcomes Register. We were bringing together a whole range of data sets, and this will be really valuable for us in terms of looking at the broader health outcomes, 30 which, of course, is what we’re all here for, and the impacts of services, and that, I think, will help us in moving forward in a more comprehensive way. So I think – so we have used the DASP as one part of our tool. We are progressing much further in terms of having better data, and then the link data, which will be 35 incredibly powerful for us as a system, in helping us direct the service mix. I think that I might just sort of ask Elizabeth for her perspectives as well because – I mean, clearly, also with the new – with the current funding mechanisms as well that the integration of DASP into that world, I think, is an important sort of connection point. 40 MS WOOD: Absolutely. And I think probably just in a high level, the service agreement documents have been in place now, and they are developed over nearly a 12-month period for the year that’s coming ahead. They are the mechanism for the state to determine and articulate what the strategic priorities are for the system, and we work very closely with each of our ministry divisions and branches to work out 45 what those are going to be for the following year. We’re also cognisant of trying not to change those too much year on year because we know it takes some time to


deliver some of those pieces of work. It takes time with the investment and, obviously, in the performance monitoring space. So some of those outcomes that we’re looking for we’re not going to see in 12 months. So how do we actually look at that over a broader period of time. 5 The agreements themselves set out the expectations of our districts and networks very clearly. They are somewhat less specific in terms of how districts and networks are to meet those expectations, but what we do have very, very clearly and robustly articulated are the performance metrics by which they’re monitored against delivering those expectations. So that’s the sort of service agreements in a nutshell, 10 and I know we’re talking about that later. So I won’t go too much further into it. MS WALLACE: Yes. MS WOOD: Unmet need is something that we have worked across the Ministry 15 again in a number of different areas, and alcohol and other drugs, obviously, has been a focus for this year. I will talk about it in broad terms. I was actually in the district for the last 12 months. So Jo has probably articulated more than what my involvement was. But for us, it’s always been a challenge in identifying what that unmet need actually is. So we often will have parts of the Ministry say there’s unmet 20 need in this area, but it’s very hard, sometimes, with the data systems we have had available to determine exactly what the need is and then how we can purchase additional services in response to that. So that is something we are working on, and it’s pleasing to see that we’ve managed to articulate that for alcohol and other drugs. 25 We then look at activity modelling approach, and, again – I know this is discussed quite extensively later. So I won’t go into huge details at this point, but in terms of how we develop our activity-based model, the purchasing of services across the state, we have quite a robust model that looks at 80 per cent population approach, but within that, there is a very strong equity and utilisation component. So we have 30 actually seen with districts where there may well be some considerable unmet equity needs – we have invested additional to bring them up to what we start to look at at a state-wide level. So that is something we do with the actual purchasing model and then similarly with 35 the KPIs, we will match that to determine – we may invest in it, but what actually are we looking at in terms of an output and an outcome for that investment. So we have come a long way in terms of where we used to just have quite input focused KPIs. We then move to outputs, and we are now trying to get into the outcome space. Again, outcomes can be a little bit challenging because of what you’re expecting to 40 see in year 1. So some of them are still quite input focused because we know there are certain things that need to be in place to deliver an outcome. So that’s, essentially, how we use the document with the various areas of the Ministry to include those strategic priorities, purchase against them and actually monitor delivery of them. 45 MS WALLACE: Thank you.


THE COMMISSIONER: Can I just ask Jo, when – to the extent that Health has used the DASP, is it a modified DASP, or is it the original DASP, or is – and I ask them – and some of her colleagues had done it – some work for NADA as – which is in the paper of a model 1 and model 2 variations of the original DASP. 5 DR MITCHELL: Yes. I’d have to check the detail on that. I don’t – that’s not – I’ve – have a presumption, but I think I would have to check the detail on which version we used. I suspect it was version 2, but I can confirm that. THE COMMISSIONER: Sure. All right. You can let us know in due course. 10 DR MITCHELL: I will. THE COMMISSIONER: That would be excellent. Thank you. And just on the issue of the DASP, it seems to me that one of the key benefits of it, if it were 15 modified to bring it up to date, to adjust it, for example, for the problem with amphetamines, as we now understand it to be – it would introduce, if it were published and widely available – would introduce a level of transparency, and I’m just wondering on that issue of transparency, I would be interested to hear what people had to say about whether things are transparent now or whether they would be 20 more transparent with some sort of tool like the DASP in place, made public, everybody knows how it works. MR KMET: Well, I think it has to be. I think everyone needs to be on the same page. I mean, I don’t have the particular experience with the DASP. Kind of a lot of 25 things happening since I’ve left, but I do have quite a bit of experience with what we did in mental health with the Mental Health Atlas, which we commissioned in Western Sydney some years ago. There’s a – it has been published as published work. So we can provide you some information about that, but what was really important about the Mental Health Atlas now it has been rolled out to most regions 30 of Australia was that everyone could be on the same page as to what was there. So we began having a common view about what was there, and it began to inform the reform agenda because, in our particular region, there was a high level of investment towards acute services, a very high investment towards, essentially – 35 what do we call it – better access, you know, the stuff that happens without very much value, but there was very little investment in what we call the missing middle, and what – and we had actually grew that as a commissioning group that the LHD and the PHN were able to move investment to more ..... missing middle type investment over a period of time. And I think that was a very, very good 40 demonstration of not only having a – an – a piece of information at one point in time, but being able to use a very similar tool over an ongoing period of time, to show how commissioning has actually worked, in the direction that we all agree. But the starting point is, we all need to know the same thing. It may not be perfect, but we need to know the same thing, and we need to have the same objectives. And in that 45 particular situation, with mental health, with the work with Louis Salvatore and others, it was a case of saying, well, we needed to deal with this missing middle, and


we began doing that, in a way that could be shown through the mental health atlas. So I – I’m very support – I’d be very supportive of this kind of work. MS WALLACE: Glen. 5 MS JAMES: I’m actually quite supportive about a national planning tool. Because, as we’ve all heard this morning, there’s no consistent approach to AOD planning, and there’s lack of clarity, really, between the state and government responsibilities around planning. So DASP – it does have its problems at the moment; it certainly needs to be updated and reviewed. But it would provide, you know, a standardised 10 national measure across both jurisdictions, and I think that’s really important, because what it would identify would be the unmet needs, and the gaps in the current treatment, you know. And I think that’s really, really important for regional New South Wales, as well, because, you know, all through the inquiry, in transcripts that I’ve read, you know, there’s these massive gaps. 15 But it’d be great to have a national planning tool that’s used by all the states, so to – and as a PHN, it’s really important, because we – we’re Commonwealth funded, and we need to absolutely be needs-based, needs-assessed. But it – but the way DASP is at the moment, it does need proper reviewing, and it needs – if we are going to 20 implement it, it needs to be funded appropriately, to be implemented across both Commonwealth and State jurisdictions, as well. MS WALLACE: Alison, you made some reference to what a planning tool like this might look like going forward; did you want to make some comments about that 25 now? And you also made a reference to whether you’d take a diagnostic versus consumption model as the basis. I’m interested in – so – interested in your thoughts about what the two might look like, going forward, ideally. PROF RITTER: Yes, sure. So if I just – I’ll just park the diagnostic- versus 30 consumption-based for the moment. I think that there are different – there are different ways in which a tool like this, which is only one tool, and one - - - MS WALLACE: Yes. 35 PROF RITTER: - - - part of the planning process, can be used. One way is that you have a more centralised model, where you have a team of people who produce the reports for a local PHN, and NGO, and LHD, and so on. The other – and that they are somehow centrally funded, in order to be a service provider of DASPM reports, tailored as required. The second option is that you rebuild the tool in a user-friendly 40 interface, and make the tool available to the planners, directly, themselves, which is in a sense the National Mental Health Services Planning - - - MS WALLACE: Yes. 45 PROF RITTER: - - - Framework Model, where they’re now training staff to become licensed to use the tool, and so on, and they’ve put it into – what’s the name


of the thing? Anyway, the software – anyway, it’s currently running in Excel. They’ve – AHW have transformed it into – something. MS WALLACE: Yes. 5 PROF RITTER: Anyway. So in a sense what you’re doing is, you’re making it available to everybody in a much more user-friendly tool – and you might have a back-room team that make sure it’s still populated with accurate data. That second model is super expensive. The first model is less expensive, but it – but it – and it would have to be a service delivery model, so the team that was producing it would 10 have to be completely responsive to the requests that come in. And there are advantages and disadvantages to those two models. What it – that are worth trying to think through. What it would, however, do, aside from the transparency point that the 15 Commissioner has raised, is that it also provides an object for people to meet around. And I know that sounds a bit psychoanalytic – it’s part of my training – but it would bring together people around a central conversation: a set of reports, a set of graphs, a set of things, that could then be deliberated on, argued about – disagreed with, of course, because it’s only one thing – but it provides a focus, that creates the 20 opportunity for the important conversations about planning. And in a sense that might end up being its most important function: rather than it producing the number, it becomes a transitional object for deliberation. On consumption versus diagnosis, that is – so I’m currently doing some work for 25 Queensland Health where they are – again, this is not a report that’s available, but as part of that work, there has been substantial consultation across Queensland about the issue of whether it should be retained with diagnosis as the epidemiology or consumption as the epidemiology. And there is currently before Queensland Health a document that summarises the perspectives of the stakeholders across Queensland 30 on that issue. And, clearly, I can request that Queensland Health share that with the Commission. THE COMMISSIONER: Great. 35 PROF RITTER: If - - - THE COMMISSIONER: That’d be good. PROF RITTER: Yes. 40 THE COMMISSIONER: That would be useful. MS WALLACE: Thanks, Alison. Really important to, sort of, hear, sort of, what the options might be, going forward, and what their comparative advantages and 45 disadvantages are. Just interested in further comments around the table. And we’ll aim to, sort of, extend a little bit into lunch. We’ll go till about 1 o’clock, I think.


But yes, interested in comments around the table about the importance of having an appropriate planning tool, and some of – particularly – some of the comments Alison has raised about the ways that that might be used. Cate, do you - - - MS HEWETT: So I second that point of Alison’s, of it being a tool that will invite 5 conversation. And - - - MS WALLACE: Yes. MS HEWETT: - - - it might be, actually, one of those tools that assists with 10 competitive tendering through NGOs, if we’re able to identify, through a transparent process, the locations where services need to go, who are the NGOs that are in that area, providing those treatment service, who’s best suited. So there – sort of takes away – think it was one of your questions, Commissioner, in the very beginning, of how we can work closer together as - - - 15 THE COMMISSIONER: Yes. MS HEWETT: - - - NGOs, instead of being competitive tenderers. And it – that tool could provide an entry point to those conversations. And the other question that 20 I had, though, Alison, was, was this the tool that had limitations with populations like pregnant women and youth? PROF RITTER: Yes. 25 MS HEWETT: Yes. Okay, so - - - PROF RITTER: But if we move to a consumption model – those limitations arise because of the absence of diagnostic - - - 30 MS HEWETT: Yes. PROF RITTER: - - - data from the National Survey of Mental Health and Wellbeing. A consumption model really increases the opportunity to expand to new populations, and it includes a harm reduction module, which is really 35 underdeveloped, and a prevention module, which is also very underdeveloped. But, again, those – that represents the beginning of the important work that - - - MS HEWETT: Endless opportunity. 40 MR PIERCE: But I’d just like to make one last point about all of this – is, this – it’s very good, and particularly your concept of the shared environment for thinking and planning. But I’d just urge this table, and the Commissioner in particular, to consider that what underlies all of this is the absolute necessity for new investment. Because we cannot adequately – we could do some fantastic planning, but with the bucks and 45 the people we’ve got now, forget it.


DR MOORE: But isn’t one of the points of the DASP to tell you what bucks are needed? PROF RITTER: Yes, indeed. And, importantly, it is agnostic to who the provider is. So you’d need to then take out your private providers. If we’re planning for 5 public services, you need to know how much is being provided in the private sector, and you need to take that away. So DASP then predicts total demand. MS WALLACE: Yes. 10 PROF RITTER: And then you need to know met demand. And then it’s the difference between the two. MR KMET: So do you calculate met demand? 15 PROF RITTER: The model does not calculate met - - - MR KMET: Yes. PROF RITTER: - - - demand; that is done separately. 20 MR KMET: Yes. I think it’s really important to know – this is the issue of – this is the mental health atlas, sort of, experience. PROF RITTER: Yes. 25 MR KMET: It’s important to know what is there, because what you’ll find is that there’ll be variety of things that are there right across - - - PROF RITTER: Yes. 30 MR KMET: - - - the landscape. And the important point about the work that we did in mental health was that we had to make a transition. We started to transition - - - PROF RITTER: Yes. 35 MR KMET: - - - from the way people were doing things, rather than ignoring them and operating in another silo. And you need - - - PROF RITTER: That’s right. 40 MR KMET: - - - to invest in that transition, and you can’t just simply say, “Well, we’re now doing this; this costs this.” It costs money to move a system, but it also costs a lot more by ignoring it and creating another system. 45 MS WALLACE: That’s right.


MR KMET: So I would just - - - PROF RITTER: Yes. MR KMET: - - - say that. 5 MS WALLACE: Yes. PROF RITTER: Yes. 10 DR MOORE: Question for Alison: so this tool, obviously, can be used to, kind of, create a notional ideal level of investment. Can you also use it as a – as a comparative tool, so that you can actually look at regional equity, and within a region, that people are providing the right mix of services? 15 PROF RITTER: Yes. You could use it in a comparative fashion, if you so chose. DR MOORE: Yes. So it could be used to address perceived lack of resources being provided to rural and remote areas? 20 PROF RITTER: Completely. Absolutely. Yes. Mary. DR HARROD: I mean, I guess my question, I think you’ve answered it a little bit already but it’s more about the people that are, like, refusing to access the system for various reasons and, you know, pregnant women is a great example. Young people 25 is another very powerful example of people that don’t want to be identified because of stigma which has been raised earlier. They don’t want to engage with treatment services at all, and are those guys accounted for in the model? PROF RITTER: To the extent that the model is predicated on a treatment rate of 35 30 per cent, the answer is both yes and no. So what you could do with a local region is say, We’re going to increase the treatment rate to 50 per cent because we’re going to have an anti-stigma campaign and we’re going to get more people into treatment and we want to predict how much – how many more treatment places we need to provide given our successful anti-stigma campaign.” 35 DR HARROD: Yes. PROF RITTER: You plug in a 50 per cent treatment rate instead of a 35 per cent treatment rate and then you can see what the gap is that you’ve got to aspire to. So it 40 can be used that way. DR HARROD: It can be used that way, yes. PROF RITTER: Yes. 45


THE COMMISSIONER: It seems to me, and this is more a comment, but the DASP seems to me to have a lot of good qualities to it, particularly if it were upgraded, brought up to date, but the ability to promulgate the DASP so everybody knows how funding is being thought about and managed would assist the NGOs. It would assist LHDs and the interrelationships between different levels of planning if 5 they stayed at Commonwealth. But almost – most of all, it would inform the public of where the shortcomings are and how urgent the need is. And as I read it, the planning that was done for NADA that’s annexed to the papers, it basically reveals, like, a shortfall of about, you know, nearly twice as many beds in 10 rehab – residential rehab. And if it’s a conservative model, which if it’s – basing it on a 35 per cent access to the people who might have that condition, that seems to me probably conservative. I would assume it has been designed that way. So if a tool like that could be promulgated, it would, I think, almost necessarily have to follow that funding would be seen as a necessity to follow what that tool is showing 15 us. So I would like to see something of that nature certainly supported and some advocacy for it. And I’m just interested to know the views across the table here. If we can talk about perhaps designing other systems or, you know, maybe the DASP is okay as far as it goes, but it seems a whole lot better than what we’re doing at the moment. Is that an impression that’s fair that I’m expressing there or not? 20 MS HEWETT: Yes. DR MITCHELL: Could I just add the other element to this - - - 25 THE COMMISSIONER: Yes. DR MITCHELL: - - - that I think the DASP in isolation is not enough, that I think that we need to have other inputs as well. 30 THE COMMISSIONER: Yes. DR MITCHELL: I mean, we’ve heard about sort of some of the contextual issues already. I’ve talked about the move, and so has Elizabeth, around going from inputs to – impacts to outcomes. 35 THE COMMISSIONER: Yes. DR MITCHELL: And, clearly, you know, what we as a group would be – wanting to ..... those outcomes as well. So I think that it’s not a panacea. I think it’s one tool 40 and there are other inputs that we need to be looking at as well because I think that it’s that variety of evidence and angles of looking at a problem which will help us to be able to design a more comprehensive system. MS WALLACE: Yes, Elizabeth and then Glen. 45


MS WOOD: Yes. Look, Commissioner, I would agree with what you’re saying in terms of the funding requirements. I think what we were talking about in the earlier discussion was that need to delineate roles with the Commonwealth funding aspects, the state funding aspects, NGOs, agencies, private providers. There’s a lot of investment. 5 THE COMMISSIONER: Sure. MS WOOD: It’s just not necessarily coordinated. And I think one of the things from a state perspective, and I make this comment coming from a district just 10 recently, is that we have identified that where potentially there is not investment from other sectors in our out-of-hospital settings, that, you know, you might consider to be a Commonwealth area, the state has started funding services of that nature to keep people safe and at home or whatever it may well be, so that for us, you know, restricted funding requirement is a challenge and I think having a better clarity 15 around who should be actually providing what would assist in that case. The other thing I think we need to think about, and ..... clearly said it in terms of looking at things not in isolation but as a holistic approach. We provide services, as Theresa said, right across the continuum of care from all of our different settings, so 20 whether it’s inpatient, ED, subacute, non-admitted – alcohol and other drug services fit across that, and it’s really important that we continue to do that and not try to silo them off. And, lastly, I would say that in terms of the work we have been doing in mental health with, particularly, the Living Well program, has been investing in out-of-hospital services so that our reliance on those acute services is for those patients 25 who are acutely unwell, and can we keep them well in the community before they’re actually requiring those services. THE COMMISSIONER: Sure. Yes. 30 MR PIERCE: But it would have to say, sorry - - - MS WALLACE: Sorry. MR PIERCE: Sorry. 35 MS WALLACE: I’m going to be my – sorry. Glen and then Larry. MS JAMES: In terms of the Commissioner’s question, you know, I think the DASP is certainly – it’s not going to be the panacea for all ills and we certainly know that, 40 but when we’re looking at the North Coast collective and what we do, what we’re finding the hardest thing to do is getting what the actual data is saying, because it’s very difficult for us to plan for outcomes, and I think that’s what the North Coast collective is all about, is planning for outcomes. So if we had a tool, such as the DASP, as I said previously, it’s not right yet, but it needs to – and then that forms 45 part of the whole planning, the regional planning around what the gaps are and how we respond and how we plan for outcomes because it’s all – and we know AOD


funding, compared to mental health funding, especially in the PHN, is really quite small, you know, so the DASP certainly, in answer to your question, will help. THE COMMISSIONER: Right. 5 MS WALLACE: Larry. MR PIERCE: And my point would follow that up ..... in particular. A lot of the very complex and very good planning discussion that was just had here will not convince treasury to spend an extra dime in drug and alcohol. What will is a number 10 like, “50 per cent of people who try to get a service can’t get one,” and that’s what drives new treasury investment, so I think that’s what DASP is really useful for, but after that I would say that I think we should be considering it in the context of long-term planning that a revised DASP model, a commitment to a 10 year timeframe for planning with incremental increases as can be borne by treasury, because that’s, at 15 the end of it – this is where money is going to come from, because there’s not enough in the health budget to start redistributing it from here into drug and alcohol. We understand that, and we’re not asking that. We are asking for new investment based on some sound epidemiological data that clearly shows a huge underspend in 20 relation to the demand that’s there, but then in realistic terms, you can’t – even if you got all the money you needed tomorrow, you couldn’t set it out and set it up in the system because we don’t have the infrastructures upgraded enough – quickly enough to be able to deliver, so we would need a timeframe for that and incremental investment to do it. 25 UNIDENTIFIED MALE: Walter? MR KMET: Look, I think that, but – though I do think there has to be a redistribution in the way we spend money. I mean, I think these kinds of tools in – 30 as I said, are very important so everyone is on the same page ..... take ..... take a view. Let’s not have – you know, try to achieve perfection here, I think, when we try to move forward with these kinds of tools, but the benefit in this is actually beginning to get reform. It’s reform, about the money, certainly, you know, showing what the gap is, but it’s also reform in being able to move things away from places 35 where they’re not effective. Now, the New South Wales Government, for example, receives an amount of money for AOD, 250 million-odd, but actually most of the money is being spent in things not counted in AOD. It’s being spent in A&Es and other areas with a lot of 40 comorbidity and so on. And, you know, and I would say, I mean, this – I would say it is then incumbent upon the government to move those resources away from hospital level into the community, and that is the purpose. The purpose is to get reform where it isn’t “my cost” or “your cost” or, “It’s not our responsibility because we’re not getting funded for it,” actually, it is a common responsibility to deal with 45 this ..... care of a person’s care. How do we all put in it? You know, wonderful co-commissioning document that’s the treasury’s document about ..... is exactly where


we need to go, that it’s not my responsibility or your responsibility, it’s not my funding or your funding. It’s around how are we dealing with this group of people and, in fact, how are we getting away from this huge investment in the acute sector and, indeed, adding to that some of the additional investments required. I think you need both. 5 MS WALLACE: Yes. Michael, and then Theresa. DR MOORE: Look, just a general observation. The DASP looks like a – not a particularly good marketing tool because what it’s saying is: spend more money, 10 which is never an attractive message. A more attractive message might be: if you invest this much money, this is the return that you’ll get. So there’s been some good work done by some of the big accounting firms on, you know, investments in mental health and the return on investment to the nation. And maybe that’s a – I think DASP is really good. I mean, you know, it provides an estimate of what you ought 15 to be spending in your area. MS WALLACE: Yes. DR MOORE: But in terms of selling it, you need to be telling people that you’re 20 asking to make that investment what their return on investment is going to be. MS WALLACE: Yeah. So it’s the messages that go with that. Theresa. DR ANDERSON: So I think, like all things in life, this is complex and, Walter, 25 although I agree with you and, in fact, I think those investments in the community, if you look at the work that’s done in Healthy Homes and Neighbourhoods, which the Ministry has supported, which was redirecting some of our acute NWAU into services in the community, and quite out there. Healthy Homes and Neighbourhoods is really about how do we get stable accommodation, how do we get parents to be 30 their best version of themselves? We’ve actually found that it has decreased presentations to ED for the whole family because it takes a whole family approach with some of the most complex and vulnerable families in this community. But I think just simply saying we’ll just decrease the acute, so if we think about the 35 impact of methamphetamine on people’s cardiac conditions, are we going to have a choice whether or not to treat someone with a drug and alcohol problem who comes in with cardiomyopathy as a result of that drug and alcohol problem? Are we going to not treat them in the emergency department, our ED? We’ve just increased our resus beds. We only had three for one of the busiest hospitals in the state. And a 40 significant number of people who are coming in have comorbidities, mental health, drug and alcohol, and we had to provide a safe environment for them. So simply saying let’s just divert into new models of care does not work. So what we’ve got to do is take a sensible approach, making sure that we’re not relying on 45 just a single tool like DASP because DASP doesn’t cover my ED. It doesn’t cover the cardiology department. It doesn’t cover vulnerable families. It doesn’t cover


what we do in our maternity services. Our district has put in significant additional investment in mental health. Most of that is actually for people with comorbidities because that is a big issue in our district – drug and alcohol problems with mental health – and there’s no doubt – we know that in the community our mental health patients are targeted by people because they are vulnerable. 5 And so we’ve got to take a much more complex and thoughtful approach because we will end up actually losing services for this population. And I think that that would be really bad. So we have to have a multipronged, multi-model approach which isn’t simple. 10 MS WALLACE: Yeah. DR MITCHELL: Can I just - - - 15 MS WALLACE: It’s all right, Jo. You go. Now, Cathryn, I was going to ask if you want to make any comments from a service planning perspective in terms of the use of modelling tools and data as well. So Jo. DR MITCHELL: Look, I was just going to, I suppose, re-emphasise some of those 20 points as well because, I mean, I raised the issue of, you know, looking at linked data as a way of looking at outcomes. But then I also think that Theresa’s other theme there about evaluation of new models of care as well is really important. And so we need to be able to agile, I suppose, to those changes over time and so, again, I think that’s just reinforcing the need to be looking at it from a number of different angles. 25 MS WALLACE: Yeah. Cathryn, did you - - - MS COX: Yeah. Look, I think the statement down the end about it being start of a conversation because I think the issue with having planning tools is they become 30 very rigid and they start getting used as industrial instruments. And certainly when we find, when we do planning, particularly with rural and regional, if you start having a workforce specification, then people who need to modify that to get the right service delivery get very constrained and limited. So I think planning tools have an absolute place in starting a conversation. The linked data that we’re getting 35 now is just so powerful that I think it leaves a lot of planning tools a bit in a different paradigm, and that linkage – and I think for something as complex as drug and alcohol when you need to look across that spectrum, it’s got so many reaches into other services, you do need that complexity. But something like that, it’s a good starting point. 40 MS WALLACE: Yeah. Great. Okay. THE COMMISSIONER: Can I just ask Alison, as I understand the DASP, it does envisage, like, care packages of different degrees so that if somebody had cardiac 45 issues related to their amphetamine use, presumably the tool could take that into account as part of the - - -


PROF RITTER: It includes emergency department presentations. It includes prenatal and postnatal and all of those sorts of things. It doesn’t explicitly include the resources that a cardiac would need to treat the comorbid heart condition so, in that particular example, the answer is no. 5 THE COMMISSIONER: Right. But, I mean, a tool like that – I mean, I hear what people are saying about, you know, using new data technology and databases and improved information that we’re gathering in, but a tool like that surely could be developed to have lots of nuances. 10 PROF RITTER: Completely. And, in fact, all of the various points that have been raised are just additional potential modules. THE COMMISSIONER: Yes. 15 PROF RITTER: It could be turned into a return on investment model. It could add a system dynamics component. It could add some policing bits in it. It can put cardiac in it. I mean, you know, you can do anything with models. THE COMMISSIONER: Yes. 20 PROF RITTER: So it’s got enormous potential if understood as a conversation starter. THE COMMISSIONER: Yes. Thank you. 25 MS WALLACE: So there’s been a bit of a – there’s been a consistent message there around the importance of having – using data and a population service planning tool, the DASP, with some enhancement – I think that’s the other comment as well, that ..... by itself as it stands at the moment has some limitations. Is important. There 30 was also that conversation about it’s useful as a way of actually facilitating the conversation. So being very clear about what it is and what it isn’t is important, but obviously it will flow into a number of different areas in terms of unmet need, the flow to how you actually – what additional funding is required, where you might actually get that funding from, where the reinvestment might occur. So there’s some 35 sort of common messages there around the importance of that going forward. Was there anything else that people wanted to raise? MR DOWRICK: Just to make comment. 40 MS WALLACE: Stewart. MR DOWRICK: A number of years ago, New South Wales Health did use a population model for the RDF, distribution formula or allocation. 45 MS WALLACE: Yes.


MR DOWRICK: So from about the mid-90s – sorry, 1990s – going back a bit now – to probably 2010 or 2005, that era there, it was used by the Ministry, because being on the North Coast, it was identified in those days that we were only receiving 80 per cent of our share of ..... growth and all that, so it was used over time carefully and thoughtfully, but not just as a blunt instrument to you know, gradually move 5 additional resources onto the North Coast, and, you know, not – you know, and that’s the way it worked. And then eventually a point where reached where all LHDs were within, you know, plus one or two per cent of a statistical formula. So – you know, and that was sort of considered a comfortable zone. So that has been used in the past with other things added to it, not just by itself - - - 10 MS WALLACE: Yes. MR DOWRICK: - - - to apply. So it has been used. I’m not saying it’s – DASP is the right tool here, but New South Wales Health did use it for a long time. 15 THE COMMISSIONER: What was the model then? MR DOWRICK: Resource Distribution Formula or allocation. It morphed ..... over about a 15 year period. 20 THE COMMISSIONER: Yes. And when sectors were within the tolerance that - - - MR DOWRICK: About a two per cent tolerance. 25 THE COMMISSIONER: Yes. MR DOWRICK: One to two per cent tolerance. But that was considered, statistically, about the right ..... 30 THE COMMISSIONER: Right. MR DOWRICK: But again, north coast was unfortunate. You know, we were only receiving you know, 20 to 22 per cent less than we should have been when I first moved there. And we ..... a very closed zone. And that was okay. We could live 35 with that. That ..... THE COMMISSIONER: And did the tool outgrow its usefulness? MR DOWRICK: I think that’s what it is, yes. 40 THE COMMISSIONER: Right. So - - - MR DOWRICK: ..... sophistication - - - 45 THE COMMISSIONER: Yes.


MR DOWRICK: - - - of delivering I guess an equity issue under the governments of the day, and then we moved towards other models that still have a population ..... so haven’t moved away from that. MS WALLACE: Yes. 5 THE COMMISSIONER: Yes. Sure. MR DOWRICK: ..... just building on from that blunt ..... 10 THE COMMISSIONER: Thank you. MS WALLACE: Cathryn. MS COX: I was just going to say, we’ve talked about sort of the outcome of the 15 intervention. I think the other piece that we’re really introducing into planning in New South Wales is actually outcome from the person’s perspective. MS WALLACE: Yes. 20 MS COX: And really genuinely patient-centred planning. And that’s asking for people for their experience of our services as well as is it the outcome that matters to them. So again, it’s not that perspective that we think we know the outcomes and we’ll provide you that, but that we actually take the time to, you know, look at surveys and ask consumers and the people that we serve, what are the outcomes and 25 experience that matter to them. And that’s quite a different way of planning rather than saying, here’s a tool, this is what we’re going to provide you. So we’re really trying to introduce patient-reported measures into our planning. MS WALLACE: Yes. So it’s taking a much broader view of different types of data 30 and information. Yes. Larry. And then I’m going to - - - MR PIERCE: Okay. No worries. Just to remind the commission that the New South Wales government has already, in principle, supported the application of a population-based tool like DASP for use in its response to the 2017/2018 Upper 35 House Inquiry into rehab services. So there’s already the commitment there. And I would just say, still, again, resource distribution formulas and DASP and other things are important, but we need to have as the basis of the conversation how – what the quantum of funding needs to be, and 235 million for a state-wide drug and alcohol program in a state like New South Wales with the comorbidities that you see from 40 your – it’s just simply not enough. It’s not even 50 per cent enough. And I would just make that ..... MS WALLACE: Thank you. We’re going to finish up now and break for lunch. We’re running a bit behind. Can I – is 20 minutes okay for lunch? So if we could 45 ..... back at 25 ..... that would be great.


ADJOURNED [1.17 pm] RESUMED [1.42 pm] 5 MS WALLACE: Thanks, everybody. I just want to basically map out what I think we should plan to do for the remainder of the round table and just check in with everybody. It’s now nearly a quarter to 2, and the aim is to finish up at 4.15. Also, I want to make sure we allow enough time at the end for everybody to a bit of a – we 10 will do a round the table and ask if there’s any outstanding issues that people wanted to comment on. So we will aim to do that probably at about quarter to 4, just to let you know. So in the remainder of the time we’ve got this afternoon – so a quarter to 2 to quarter 15 to 4, we want to cover two topics, and they’re both – sorry – two sub-topics, and they’re both within the broader topic of the funding of alcohol and other drugs services, have a conversation about the service agreements and how they operate, but we also – I want to make sure we have enough time on the contracts with non-government organisations and what could be done to make that work better for the – 20 for everybody, but particularly NGOs. I’m going to propose that we move fairly quickly on the service agreements and to allow enough time on the NGO contracts. I’m also going to suggest that we don’t do a physical break for afternoon tea, that we just – yes. You can go and grab tea or 25 coffee at any time. I might just, at an appropriate time, allow a bit of a short break to do that. Are people happy with that, we just sort of keep working through? I’m just conscious that we want to make sure we get everybody’s – get – give everybody a chance to contribute. 30 So we’re going to shift now to thinking about the way that the local health district service agreement – agreements operate, and there certainly has been some changes to the process for this year particularly in relation to the change of – changes to what’s in the service agreements for alcohol and other drugs this year. Elizabeth, you already have given a bit of an overview of the process. Did you want to make 35 any additional remarks about – particularly for – and how the system worked this year for AOD volumes, and then, Jo, I might go to you and talk about – I think particularly interested about the – why purchasing volumes this year, which is the first time I think it has been done explicitly and also about the KPI, that it is in the agreements, why that, why not others. So just – you know, a bit of a – bit more 40 delving into detail about that. So Elizabeth - - - MS WOOD: Sure. So, I think, broadly, I’ve sort of articulated what the service agreements are, how they are structured and how they function. I think, probably, I would ..... in terms of what components are in there for alcohol and other drugs. I 45 think it’s important to say, again, that the service agreement is a document that covers all of our ..... branches and divisions and strategic inquiries in the Ministry,


and we are very much guided by those policy areas in telling us what needs to go in there, and so I think Jo will be willing to speak to that. The other thing I just wanted to raise was that the service agreement document itself is actually only one part of an over-arching performance management framework for New South Wales Health. 5 So the service agreement document, as I said, sets out the expectations and the strategic priorities for the system. It’s very clear in articulating the purchase volumes, the funding that’s associated with that, and then specifically the KPIs that we will be looking at for that year. Some of those are consistent. Some of those are national, and some of them will come in and out in a year depending on what is a 10 primary focus for a particular branch. As I said, we try to keep them as stable as we can because we do acknowledge that, in particular, as we’re moving to more outcomes type KPIs – and that has moved further in some areas than others – then it will take, sometimes, a number of years to actually see that actually come to fruition, but what is important is the performance framework that the document sits in. So we 15 have a very robust process whereby we meet quarterly with each district and network, and we go through their performance against each of the KPIs in the agreement. We also have representation of each of the divisions and branches of that meeting. 20 So it’s not to say – and I think this is the most important part. If there’s something that’s not in that document, it doesn’t mean we can’t raise it with a district and network if there is a concern. And that can come up from any aspect of service delivery right across acute setting to non-admitted. I there was something that came up from an NGO colleague that came up through one of the Ministry branches, they 25 could raise it through that meeting with the district. So there are opportunities for that. I just wanted to be clear that we’ve tried to streamline the service agreement as much as possible. It was previously pushing out to somewhere between 60 and 70 pages long, and I 30 think you will all agree in terms of some of the comments I’ve heard coming up around in NGO focus areas that having a huge raft of KPIs that you are required to report against is (a) probably quite unhelpful and time confusing, but (b) it doesn’t really give you the opportunity to focus on what is actually critically important for service delivery. So the KPIs that we have in there at the moment are seen as a flag 35 to basically start discussion with a district. It may highlight something that we wanted to have more of a discussion with them about, but we don’t just look at the KPI in isolation. So Jo, I might get you to talk through your particular areas. DR MITCHELL: Sure. For 2019/20 – so this current financial year – there are five 40 AOD measures in the service level agreement. There’s measure in relation to opioid treatment, and that’s looking at sort of a shift from methadone to buprenorphine. That has been in there for a couple of years now. We have a measure on consultation liaison. So that’s the number of ..... measure. It’s not a – there’s no target attached, and then we have targets attached to admitted and non-admitted activity for AOD, 45 and so the targets have been negotiated as part of the process for the service-level agreement, and the reason that we’re focused on activity and NWAU – so the way


that’s counted and within the system is because we recognise that it was in – it’s in an important area that we need to grow, and so for the first time, we’ve got targets against AOD as part of the service-level agreements. Now, clearly, as Elizabeth has mentioned, it’s not the be all and end all. So it’s a bit 5 like our earlier discussion. So the service-level agreement is kind of like the top of the pyramid in terms of – but there’s a whole range of other things that happen underneath that. And so in AOD, some of the other things that are important in – I mean, the good thing about being in the service-level agreements is the dialogue, and it’s actually being able to monitor and monitor the performance over time, but it’s 10 also then about being able to talk about sort of some of the barriers that might be impacting on performance as well. So as well as having the quarterly meetings with the chief executives and their executive team, the Centre for Population Health has also established local discussion with AOD counterparts so that, again, there’s that transparency, and we understand, you know, where things are at from a service 15 perspective as – and how that feeds into the performance process. We also, in terms of a performance system, look at – you know, we have reporting requirements on government commitments. If there’s a – you know, a public or clinical incident, there are reporting mechanisms for monitoring – for addressing 20 those, and we also, you know, as a – as part of our role as system manager within the Ministry also liaison when there are some particular capacity issues and can work with local health districts to help in relation to sorting some of those issues out, and a key example is with – if an opioid treatment prescriber unexpectedly retires, we will work with the LHD to help make sure that those clients are actually connected into 25 other services whilst that’s being dealt with, and then importantly, as well, as I’ve already alluded to, within the Ministry, we are really strengthening our surveillance capability and capacity, and so, again, I make another – I suppose it’s like – I will give the example of how we work in HIV for – as the way in which we’re wanting to move in the AOD sector as well. 30 So HIV – there were two indicators in the service-level agreements, but over time, were able to develop really excellent surveillance data reports, which come out quarterly where we have conversations across the sector about what that data means and how we should continue to respond. And so we are building a similar kind of 35 capability in AOD, but I think it’s fair to say that we’re at the beginning stages of that, and so just – I think I used that as an example to illustrate that the KPIs are just one part of the story and that it’s – there are other things and other mechanisms that we use and will be building to have that better understanding of performance across the system as a whole. 40 MS WALLACE: Jo, could you just comment on the particular indicator around consultation liaison and, sort of, why that one was selected as opposed to, say, something else? Yes. 45 DR MITCHELL: Well, consultation liaison is an area where we’d done an evaluation which had an economic component, and so it’s a cost effective


intervention. There’s a potential link in too as well about if you are able to identify people in the ED setting and then connect them into care, there’s the potential also to reduce readmissions as well, but also to have the connecting that person into care. So it’s really acting on the results of that evaluation which demonstrate that it’s an effective intervention both in terms of impact for the individual but also impact on 5 our services. MR KMET: Is that the evaluation from 2014? DR MITCHELL: Yes. 10 MS WALLACE: And given Elizabeth’s comment ..... about sometimes the indicator might be in place for a period of time rather than an ongoing, do you imagine that this one will be an ongoing measure or - - - 15 DR MITCHELL: I think this one will be ongoing for some time. But, I mean, really, the KPI landscape is very hotly contested. MS WALLACE: Yes. 20 DR MITCHELL: But there’s a point at which the indicator will have done what it needs to do. MS WALLACE: Yes. 25 DR MITCHELL: And you might then need to change. And so that’s the – it’s a helpful tactic for us - - - MS WALLACE: Yes. 30 DR MITCHELL: - - - is that you can get some movement, and then you might think, well, what’s going to get us to the next set of movement. MS WALLACE: Yes. 35 DR MITCHELL: But this is just the first year that we’ve had the targets, and I think that that’s – I would expect that we would continue with those targets for at least a couple more years, and I think we’ve heard that this is a long-term issue that we’re working on. 40 MS WALLACE: And I’m conscious of the conversation already about, you know, you want to get – it’s a balancing act between having too many KPIs and, you know, making sure you select the right ones. Maybe from the LHD chief executives, interested in any comments you want to make at this point about how the shift this year in the ‘19-‘20 agreements to explicit block funding – sorry, moving from block 45 funding to purchasing activity for alcohol and other drug services and the


introduction of the new KPI, just any comments you want to make about what that means in terms of your own planning of services and delivery of services. DR ANDERSON: Yes. Do you actually have a copy of the Sydney Local Health District - - - 5 MS WALLACE: We do, yes. It’s included. DR ANDERSON: - - - service agreement in there. And as Elizabeth said, the process that you go through is a very robust process, and there’s no doubt, I think, 10 from my experience where we were in 2011 going to activity based funding, and someone said it before, it gives us a language in which we can communicate more effectively with each other. The block funding doesn’t. I think being able to count activity was important was important but the service agreement isn’t just about the activity, and I think reading the context of that in terms of the plans, what are the 15 priorities, etcetera, I think are really important and local health districts have an ability to indicate their priorities. And you will notice in the Sydney Local Health District priorities there are quite a number which, when you look at them, you go, well, that has nothing to do with drug 20 and alcohol, but if you look at, for example, the redevelopment of Concord Hospital under the capital works, it very much involves drug and alcohol and how we’re working on our drug and alcohol services, both at RPA and at Concord. So that’s inherent in there, our clinical services plan. If you go through all of our clinical services plans you’ll find drug and alcohol in the majority of them, including oral 25 health. You know, Sydney Dental Hospital is one of the most well located health services in the country servicing one of the most disadvantaged populations, and so we’ve been working on the model of care around integrating primary care, integrating mental health, drug and alcohol into what we do within oral health. 30 The National Centre for Veterans’ Healthcare is a new model of care for our returning veterans, and we know self-medication is a major issue, and so that model of care involves drug and alcohol, mental health, our pain people as well as the obvious physical issues. So when you go through, it looks like drug and alcohol may not be there and well represented, but it’s actually in everything that we do, and the 35 KPIs, as Elizabeth and Jo said, are really there to highlight – you know, to be a point of highlight so that when we have our annual service plans, I cascade these. My performance agreement reflects the annual service plan, and what we’re doing in terms of models of care are actually explicitly outlined in that, and then that’s cascaded through all of my staff, including the General Manager of Drug and 40 Alcohol and the Clinical Director of Drug and Alcohol, but also through mental health, through the general managers, etcetera, and then we report against that performance. So those quarterly performance meetings that we have are really important. They 45 have representatives of the various portfolios of the Ministry, and to say they interrogate us, I think, is an understatement once a quarter. I mean, it’s really good.


I think we have very robust discussion about what we’re doing to meet those KPIs. It’s not just a tick box exercise where they go, you know, “You’re doing a good job, Teresa. Off you go.” They’re quite lengthy, robust and very informative. Members of my board attend those performance meetings so that they can hear what are the issues that we need to talk about. So I think it’s really important that we don’t just 5 take these agreements superficially and not recognise the depth of what sits behind these. And the performance framework, I think, is a really robust framework that the Ministry has to manage the performance of the system as a whole, and, you know, we’re rated nought to four; four is not good. Zero is good. And, you know, I know my fellow CEs we look at that every month to see where everyone else is at, and if 10 Stewart is doing some really great things, you know I’ll ring Stewart and say, “Well, what are you doing in that - - - MR DOWRICK: She’s on the phone all the time to me. 15 DR ANDERSON: - - - “that I might be able to leverage off.” THE COMMISSIONER: So, Teresa, can I - - - MR DOWRICK: Yes, just – sorry, sorry. 20 DR ANDERSON: Sorry. THE COMMISSIONER: Sorry. Can I just ask you, just by way of a practical example then, something like the complex presentation of somebody who’s in an 25 amphetamine psychosis coming into ED. DR ANDERSON: Yes. THE COMMISSIONER: All the complexities around is it a mental health issue, is 30 it an emergency issue, where should this person be, do we have enough room for that person - - - DR ANDERSON: Yes. 35 THE COMMISSIONER: - - - in ED, where do we keep them for the next 24 hours, etcetera. I mean, are those the sort of issues, if it becomes a problem in terms of resource – using up resources, is that the sort of issue you could raise at one of the quarterly meetings and - - - 40 DR ANDERSON: Absolutely. THE COMMISSIONER: Yes. DR ANDERSON: And that’s exactly one of the issues - - - 45 THE COMMISSIONER: Yes. Good.


DR ANDERSON: - - - that was raised because, as I said, at RPA we only had three resuscitation bays and many of these patients, when they come, actually need resuscitation. They need to be very closely observed and my drug and alcohol patients, like my mental health patients, deserve to get the same level of care as anybody who comes in - - - 5 THE COMMISSIONER: Sure. DR ANDERSON: - - - in that very critical condition. And the environment was not an appropriate one, so we worked with the Ministry and we have refurbished the 10 resuscitation area. We’ve actually designed it so that a patient with a mental health, drug and alcohol problem can actually have a bit more of a quiet space because it’s such a busy environment. It’s not a locked area but certainly the clinicians and our consumers were actively involved in the design of what that should look like, but the model of care actively involves our clinicians as well as our consumers, and for us it 15 also involved our security staff and our peer workers because we wanted to make sure that we were considering the whole needs of our consumers. So that was raised at the quarterly meetings. It was raised with the secretary and the deputy secretaries, and we worked on the 20 model of care in relation to that. And all of those discussions in terms of the activity were part of our negotiations, as Amanda and Stewart would’ve been involved in similar sorts of negotiations with the Ministry of Health. One of the things that the Ministry had the districts look at was in terms of integrated care, and, as I said, we put in a submission around healthy homes and neighbourhoods. We’d done a pilot in 25 relation to that. The criteria is for complex vulnerable families, many of whom have drug and alcohol, mental health problems, and, as I said, that looks at homeless, looks at how we can get access to stable housing, access to general practice, trying to hold families together. And what’s really interesting, and I have to say I didn’t think about it at the time, we – it would be great if, you know, hindsight I should’ve and 30 then everyone could say I was very wise, but we were looking at how do we keep the families together with Healthy Homes and Neighbourhoods. And as an aside, we decided to look at ED presentations for the whole of the family, and these are complex families, as I said. Many have got chronic conditions as well as their drug and alcohol and mental health problems, and we found for the whole family a 35 significant decrease in ED presentations with that model of care and we’re now expanding Healthy Homes and Neighbourhoods as a result of formal evaluation, because I think this is not about what do we – what feels good. It’s, “Have we got real data that shows that these different models of care work?” And I’m very pleased we could say with that particular model, we’ve got very clear evidence that it does. 40 MS WALLACE: Yes. Mary. DR HARROD: I guess I’ve taken onboard everything that everyone has said here but it’s hard for me as representing consumers to not be jealous of these mental 45 health KPIs in this agreement. Wow. And, like, the KPI that Jo mentioned, people transferring from methadone to buprenorphine, that can cause real significant issues


for individuals, you know. And I’m just saying that as a flag, like, you know, people have been sort of shamed by treatment providers when they don’t want to transfer or they want to transfer back, you know. Buprenorphine doesn’t agree with everyone. And, you know, like, I’m not criticising it specifically, just saying that this set of mental health KPIs is pretty sweet. 5 MR DOWRICK: ..... time. DR HARROD: 100 per cent I realise that. Yes, like, I - - - 10 MR DOWRICK: So ..... DR HARROD: I get everything that everyone said, but that’s – that would be very aspirational. 15 MR DOWRICK: Yes, they’ve got better and better and better. DR HARROD: Yes. Yes. MR DOWRICK: I mean ..... sorry. 20 MR KELLY: Just as a comment following on from what Mary said, those – when we look at those KPIs, particularly on page 29, they reflect so closely with many of the issues that we have heard over and over and over again through the course of this inquiry: absconding from emergency, consumer experience, being in the ED for – 25 some of the evidence we’ve had has been up to 100 hours across the state; peer workforce; pathways to community. So it is quite striking to see them there in that context. DR HARROD: And I recognise completely that that’s a work in progress and, you 30 know, probably something that would, you know, take place over many years. MR DOWRICK: Years ago it was ..... just report on what activity, occasional service and ..... it was never KPIs. And even with those, the good thing that the Ministry has done is ensure that the industry themselves got behind those KPIs. 35 DR HARROD: Yes. MR DOWRICK: And said, “Does this make sense? Are they ..... right?” So they’ve been evolving because with D-and-A, I’m sure it would be the same with 40 drug and alcohol, the need to spend more time with our workplace to make sure, “Are we getting the right ..... “ DR HARROD: Yes. 45 MR DOWRICK: Does it mean what we think it means or is it telling us something different? So it’s going to take up .....


DR HARROD: 100 per cent we couldn’t have this now, you know. MR DOWRICK: Yes. DR HARROD: I totally get that. 5 MS WALLACE: Nick and then Amanda. MR KELLY: Just in a very simplistic level with the example that the Commissioner gave about the complex presentations to emergency of someone in an acute 10 intoxicated state, I would like to understand if someone could help, where that presentation would have fit in terms of your ABF purchasing volumes before 2019/20, and whether they now fit somewhere else, because there are specific alcohol and other drug purchase volumes in the service agreement. 15 MS WALLACE: Elizabeth. UNIDENTIFIED MALE: That would have been acute. UNIDENTIFIED FEMALE: That’s part of the acute. 20 MS WOOD: Yes. It’s – well, it fits in across – it’s probably all of them. So it will start in the ED, if that’s where they present. It will then fit into their acute episode. They may well then become subacute and they will fit into that, and then they may well be discharged, and then they would be seen, potentially, in a non-admin space. 25 So it occurs right across the whole continuum. MR KELLY: But is there any difference pre-2018? MS WOOD: It really comes down to the data capture. For us that’s one of the 30 critical aspects. So when they do clinically code the patient’s record. The code is then actually put back into the EMR – well, they take it out of the EMR. That’s then coded and then it actually informs what is in the HA and that’s where we pick it up in terms of the developing a baseline going forward for the following year. So it’s really critical that that coding and where it’s captured is accurate because what we 35 were finding, particularly for non-admitted, the data capture in that space has vastly improved in recent years but, potentially, it wasn’t being captured against the right activity stream, if you like. So it wasn’t necessarily reflective appropriately of where that patient was receiving their care. 40 MR KELLY: I just still don’t understand, particularly from LHD perspective, what the effect of the use of what I’m told is incredibly valuable real estate, of having these new purchase volumes in there. I just don’t understand. I understand that what you – that there’s very good reason for what goes in there and that the decision to put something in there is a big decision, but I do not understand either, really, what 45 justified that big decision being made in 2019/20 or what it means for the LHDs that’s in there.


MS LARKIN: So – can I comment? MS WALLACE: Yes. MR KELLY: Yeah. 5 MS LARKIN: And Elizabeth has done it very well, but if I can comment on it, Elizabeth, from an LHD perspective. MS WOOD: No, please do. Yeah. 10 MS LARKIN: Prior to 2011 we were not in an ABF environment. We did not have service level agreements. We really were funded – if I’m looking around the room here, pretty much year to year you just got whatever you got last year and you may have got CPI. So understanding what the system was delivering in terms of – let’s 15 just talk from an activity point of view – was very hard to articulate. It took us really – I’m just thinking. We’re not nine – be nearly nine years in. The first four years to actually move into an environment, two things: (1) ABF, so we started to be able to say, you know, what volume of ED are we purchasing at what kind of level, what’s the increase, etcetera. But then also in the service level agreement that says this is an 20 arrangement between us and the ministry about what we’re going to purchase. But I need to tell you where we started to where we are today is a much more mature system, very different. And we’re able to, therefore, have a clear picture, at least at an activity level, although that’s matured too, in terms of what we’re doing. Where 25 we started was very much in the acute environment, though. So it took us a while to bring in things like mental health outpatients, oral health services have just come in, drug and alcohol services. And I think what we’ve – and I’m talking kind of a bit on behalf of the system here, but what the system has tried to do is bring the whole picture together in terms of what we do at a district level. But it’s taken us a while to 30 get there. So I really do think to understand where we’re come from to where we are now is really critical and we really did start in the acute system with the acute services that we were doing, and then we’ve built that picture over a period of time to understand 35 what we’re now delivering in terms of care. The value – I’m talking about from an LHD point of view – in answer to your question, is that we’re starting to quantify the defined elements around drug and alcohol. So what we’ve clearly argued is that drug and alcohol is part of service delivery in multiple elements of the system. But there’s also some core parts around community based care and inpatient care that we can put 40 a fence around and say, “This is what you’re doing. This is what you’re purchasing. This is what you’re delivering,” around that, knowing that there are elements through the other parts, though. So I’m assuming, and I’m not in Elizabeth’s unit, but over the next couple of years 45 we’ll see some refinement of that as we define it, but acknowledging that things like mental health, drug and alcohol – I’m just trying to think of some others – possibly a


bit of oral health are not solely only in their particular defined area. They also sit across the system. But it starts to give a sense around what it is we’re doing. The system is then saying to us, “Well, this is what we’re purchasing. Are you delivering it? Are you hitting some of those needs in your local communities,” etcetera. So it starts to really work up that picture in a much more – I think for us in a much more 5 defined way. And so – I was going say so for me in relation to what this has done, I’ve got to say, when we moved it was like okey-dokey. Got to get on the next little – you know, the next little bit that we’ve got to understand – because we did a whole lot of work 10 around mental health and oral health so to me this is the next group we’re defining – being clear about the activity, being clear about the types of KPIs that best reflect the nature of the work that’s done in drug and alcohol. I’m assuming we’ll pick up some consumer ones as we better understand what we’re delivering and we’ll mature it over the next couple of years. But that’s really what’s happening pretty much every 15 – every year that’s a refining of the system. So I’m talking at an LHD level. I now know, okay, so that’s the quantum of activity that I’m being purchased – that’s being purchased. This is the volume of dollars that I’ve got around it, you know, being sure that I’m delivering that – funding to that 20 level. All of those kinds of things is what it does. MS WALLACE: And at the quarterly - - - MS LARKIN: I don’t know whether I’ve answered your question, but that’s what it 25 does. MS WALLACE: And at the quarterly review meetings, your level of actual activity against what you were - - - 30 MS LARKIN: But not only at the quarterly – that’s monitored on an ongoing basis. MS WALLACE: Monthly. Yeah. MS LARKIN: The quarterly meetings really are a snapshot to say that’s what’s 35 happening at that point in time. MS WALLACE: Yes. MS LARKIN: If you’re going significantly off target, I’m telling you, you’ll get a 40 call to say, “Is something happening here? Is your coding right? Is your activity going” – you know, because that’s what the ministry wants to know, that we’re actually delivering a quantum of work in that particular area. DR ANDERSON: And there’s a monthly report for every Local Health District and 45 at a state level, and there is no doubt all of us go on and check out what everybody else is doing, what their trends are doing. Except Stewart. But, you know, that’s


really important because why do we do that? Because, as I said, if Amanda or Stewart have got significant improvements in an area where I’m struggling, I’m going to want to know what it is that they’re doing, and so it gives you an objective way of being able to measure that. And our boards look at that in detail. 5 MS LARKIN: Yeah. But my only last comment would be I think – sorry. Sorry. THE COMMISSIONER: That’s all right. MS LARKIN: I think we do need to understand, a bit like mental health, it’s not 10 solely a mental health budget. There are lots of elements of drug health and mental health that sit in other budgets and are involved, like the patient who comes to the emergency department who is – you know, possibly stays 24 hours in my place – I’ve got to say to you – and why? Because they’ll want to – they’ll want to detox for a period of time, be in a position to be able to assess – understand whether there’s 15 any resource – any beds out there that we can move them into. I mean, all of those kinds of things that potentially will impact on it. But it’s very dispersed, both of those are. And that’s okay. It’s just everyone else understanding the complexity and the funding arrangements for that for articulate that to you. 20 THE COMMISSIONER: Can I just ask on that point where – and I get it that obviously drug and alcohol will be involved in emergency and other sorts of presentations. MS LARKIN: Yeah. 25 THE COMMISSIONER: But isn’t it possible for drug and alcohol intended funded to get lost in that sort of application? It might be a second cousin to a more immediate need that the LHD seems to feel that it has at the time. 30 MS LARKIN: So I’m just going to argue a reverse argument. THE COMMISSIONER: Yes. Sure. MS LARKIN: Can I do that with you? 35 THE COMMISSIONER: Sure. MS LARKIN: Drug and alcohol patients, like mental health patients, have the right to the highest quality of services across our health system. 40 THE COMMISSIONER: Sure. Yeah. MS LARKIN: Because you present to one of the emergency departments with a drug and alcohol issue should be no different than presenting as a cardiac one, 45 etcetera.


THE COMMISSIONER: Sure. MS LARKIN: You should be treated, you know, in essence, with the same and provided the same level of care. So I don’t see it in that context. It’s the ongoing care that we need to define in terms of rehab support, etcetera. Yeah. 5 MR HENDERSON: That doesn’t happen. DR HARROD: Yeah, it is different. 10 MR HENDERSON: It just does not happen. You know, I’ve - - - DR HARROD: I have a person that works for me that was – I won’t name the LHD but was – presented in an emergency department with acute amphetamine issues and was locked in a closet for 24 hours. So yes. They should. 15 MS LARKIN: And I – and can I emphasise my words of “that’s what they should” – yes. MR HENDERSON: Should. Yeah. I heard you say “should”. Yeah, yeah, yeah. 20 MS LARKIN: All right. So I just want to – I really do want to clarify that. MR HENDERSON: No. I did hear you say “should”, but, you know, like, just need to make the point that that’s not what happens. 25 MS LARKIN: Yeah. No, no. I hear what you’re saying. MR HENDERSON: Even down to the level of – when we have to take someone to a local hospital A&E for some medical treatment, comments are like, “Well, this 30 person was residing in South-East Sydney or, you know, Far North Coast three days ago. Now they’re in your facility, and you’re here at our A&E trying to get them treated. They should have been getting treated back up where they live before they came here because this is impacting our budget”. 35 MS WOOD: Well, actually, in terms of that particular comment there – at – where the patient is, is where the funding is ..... doesn’t matter where they actually live. MR HENDERSON: I’m just telling you, like ..... and - - - 40 MS LARKIN: No, MS WOOD: No, no. I appreciate that. MR HENDERSON: And the other thing is, you know, getting access to the range of 45 allied health services as well as medical health services that people need who don’t see GPs, who don’t manage their dental health care, who don’t manage things like


diet and nutrition so that they’re as healthy as they can be and don’t exercise. So we need to be able to access all of those range of services as well as that critical component of mental health care as well. And just - - - MS LARKIN: Yeah. I agree. 5 MR HENDERSON: And just where I live – you know, where I live, you know, the mental health services up there are just – they’re completely smashed with demand. You know, we have a great working relationship with the teams, but they’re smashed with demand, and then when we bring our clients in on top, you know, it becomes 10 even more difficult. So the service system itself - - - MS LARKIN: ..... MR HENDERSON: - - - isn’t able to respond. 15 MS WALLACE: So absolutely important to acknowledge the difference between what should happen and what potentially – yes, what does happen. MS LARKIN: Yeah, absolutely. Yep. 20 MR HENDERSON: Yeah, yeah. MS WALLACE: But to go back, Commissioner, to your end, the original question was around do you end up – you know, in some ways - - - 25 THE COMMISSIONER: Is there a leakage of - - - MS WALLACE: Is the – yeah, yeah. 30 THE COMMISSIONER: Yeah, of funds that – yep. MS WALLACE: As you move from funding of drug and alcohol service to purchasing volume, does that help or hinder that - - - 35 MS WOOD: Well, I mean, I think it actually helps it because in here, we’ve now articulated exactly what the activity is against those services. So if you are not investing in them to deliver them, you are not going to meet your activity targets, and that’s where the flag is going to happen through that reporting process and the performance meeting. So the whole idea, really, of activity-based funding, you 40 know, if we’re going to go through a spiel of ..... I will do that – is to actually make it more transparent and clear as to where the investment and what the service delivery should be. MS WALLACE: Yes. 45 DR ANDERSON: So the dollars that we get for drug and alcohol in Sydney - - -


THE COMMISSIONER: Yep. DR ANDERSON: - - - Local Health District – all of that goes to the provision of drug and alcohol services, none to the emergency department and cardiology and mental health, etcetera. That’s in addition to the designated dollars that have been 5 given for drug and alcohol. So the leakage, if anything, is the other way because the reality is, as Amanda said, members of our community who’ve got drug and alcohol problems are coming into the emergency department, need to be given the appropriate care, and, albeit, not everyone gets the care that we would like them to have, I have to say, I’ve been in the public health system for quite a while – since 10 1981 – and I have to say that the journey that we’ve been on, I believe that the equality of care that our drug and alcohol patients get now and the multidisciplinary multi-system approach is actually getting better, and what we’ve got to do is make sure we reinforce those things are getting better and not throw the baby out with the bath water. Is there actually recognised what is going well and reinforce that and 15 invest in that and then gradually change the other models of care. MS WALLACE: Yes. And I know Walter has had an outstanding - - - MR PIERCE: Then if that’s the case, I would argue that out of a fairly meagre state 20 budget of 231 or 235 million that given that the public system is doing what it should be doing and treating drug and alcohol with co-occurring health and mental health issues, as part of the population they would treat anyway, that those specialist funds be redirected to non-hospital based drug and alcohol treatment specialist service providers regardless of who the provider is. In most cases, that is NGOs, but it 25 doesn’t always have to be. Then we would be getting really good bang for the buck in an overall sense because the burden of alcohol harm – drug and alcohol harm could be captured as part of the public health system’s core responsibility. MR KELLY: Is anyone able to tell me how we know where that $231 million is 30 currently being spent, or where it gets spent? Just very – it’s probably not something that can be explained simply, but how we know where it’s spent. DR ANDERSON: So – yep. So 16 million comes to Sydney Local Health District, and it’s allocated to our opioid program, to our consultation liaison programs, 35 specifically to our psychologists and other people who are treating out drug and alcohol patients. It does not go to the emergency department other than for their consultation liaison, drug and alcohol worker. MR KELLY: And is the mechanism by which it gets to you the service agreement? 40 DR ANDERSON: Yes. MR KELLY: And is the mechanism by which you report back on how it’s being spent the reporting framework that’s with ..... part of that. 45


DR ANDERSON: It’s part of that, but we also do – we do additional reporting through to the Minister. MR KELLY: Right. 5 DR ANDERSON: So it’s not – that’s what I was trying to explain before, and I obviously didn’t do a good job. There – we report on more than what is in the service agreement. There’s more detailed reporting. Jo spoke about HIV. We have similar detailed reporting that goes to other parts of our work. 10 MS WOOD: I think the other thing that’s important in terms of the actual specific funding of it, there’s state-only block funding. So that is where – when ..... makes the determination of what is in scope for ABF and what is not in scope for the ABF, some of these services will fit into that state-only block funding. So it will be spread across, and we can take it on notice in terms of getting more specifics around it, but I 15 think the reality is it’s actually spread right across everything because that’s how we integrated services through ABF and also supported – rather than trying to fit everything into an ABF paradigm, where it has to be block funded, we ..... DR ANDERSON: We’ve done that. 20 PROF RITTER: I think the key question – I think the ABF is a bit of a distraction, actually, and I think this service agreement is probably not particularly relevant to alcohol and drug treatment per se – well, I might be wrong. The key question is what proportion of funding to LHDs for specific drug and alcohol treatment is provided 25 through the ABF mechanism versus what is provided through enhancement, special grants, program initiatives, etcetera, and my hunch is that it’s really small with the ABF, and most alcohol and drug treatment money comes through a different mechanism – currently different mechanisms from the ABF, but I might be wrong, and the money that you’re talking about is not ABF money. That sits completely 30 separately. That’s not part of the ..... blah, blah. MS LARKIN: Well, I think probably for today, it might be good to just take it on notice ..... answer the question ..... 35 MS WALLACE: Yeah. Could I suggest – and I know Walter’s been patiently - - - MS LARKIN: Just answer the question clearly. MS WALLACE: Yeah. So the – just to be clear, the key question is of the amount 40 of money that the state says it spends on drug and alcohol funding, which is quoted at 235 million – so where does that – how does that go – flow through to local health districts. DR MITCHELL: Yeah. I’d just make the comment, too, that we have provided 45 information around what goes to the local health districts, what the Ministry funds to NGOs, etcetera, as well as some information about what the Ministry – so the Centre


for Population Health has as well within our budget, which goes some way towards answering that question. MR KELLY: It does, and the reverse question which is - - - 5 PROF RITTER: But it’s the reverse question. It’s the reverse question. DR MITCHELL: Yes. MR KELLY: - - - how you track back, how that money has been spent. We’ve also 10 asked some questions about that. I accept that, but - - - MS WALLACE: So I think - - - PROF RITTER: It’s the proportion of ABF that is alcohol and other drugs, not the 15 block grant. We know that. MS WALLACE: So it sounds like there’s a question that will be formulated back to the Ministry for additional information based on what has already been provided as well. Yes ..... 20 MR KMET: Just in relation to that question, I think it’d be good to ask how has that changed over time, because one of the things that – I mean, the reality is you can’t manage what you don’t measure. I think these agreements absolutely do that, and I think the history of ABF has been that you can actually do that where you haven’t 25 done that before. That’s very positive. So drawing a line between that and what was discussed earlier in relation to the planning tool, what does that look like at the other side? And, you know, what ABF – just like fee for service, what it actually does is actually perversely makes a system more hospital-centric and – because what you’re doing here is you’re justifying more and more work, and I – you know, what I would 30 like ..... the argument I have for many years with Western Sydney Local Health District, what is your proportional ratio of funding that’s changing from going hospital based to the community, and the reality was certainly mental health, that was actually getting more and more weighted towards hospital and acute care, because you could justify that care. 35 UNIDENTIFIED FEMALE: Yes. MR KMET: And indeed the national figures show that the proportion of funding for acute mental health has increased to acute care significantly over the last 15 years. 40 MS WOOD: Yes. So in terms of that comment, in 2017/18 for mental health, in line with the Living Well strategy, we actually took the growth that was going to be allocated to mental health services and we applied it to the actual ..... 45 MR KMET: So that’s great.


MS WOOD: So - - - MR KMET: Yes. So I think that’s a great – that’s a great initiative in terms of – but, you know, at the end of the day, the question for mental health, as it will be for AOD – what is that target? What does that number look like over a period of time, 5 and how do we ensure that that number is part of this mix of bucket of resources that we’re ultimately saying – you know, can’t stop people coming into hospital and treating them, as we said earlier, absolutely not, but what commitment is there to get from this number to that number? In mental health nationally, that has gotten a lot worse. And I don’t know what the numbers are in AOD. I would like to know what 10 the numbers are, but I suspect it would be not too different, and I suspect over time there is no target to say well, of this bucket of resources is how we’re going to spend it. MS WOOD: And I think it’s just one of – sorry, Jo – we have tried over the last – 15 from 2011 to now, 2019, we have start moving into activity-based funding for a couple of reasons, and one is that the growth is applied into the ..... much more - - - MR KMET: Yes. It’s a good model. 20 MS WOOD: ..... so I think that’s one aspect. So once we have got a service that’s – the data capture is accurate enough that we will move it safely into activity-based funding, it gets growth year on year. The block has got smaller over time as we have moved more services into that space, but we do acknowledge, as I said, that there are some services that do still need that block funding element of it. I think that there is 25 going to probably be still some confusion around exactly the dollars spent, because as per any other service, whether it’s cardiology, respiratory, dental, anything, it’s going to spread across all of those streams, and pulling out alcohol and drugs would be just as difficult as doing that with any of the others, but as we said, we will take it on notice in terms of that. The other aspect that we also need to think about in terms 30 of the rule is the commonwealth shared funding for the small ..... facilities. MS WALLACE: Yes. MS WOOD: So some of those facilities do not meet ABF requirements, so they are 35 sitting in a block funded area. We recognise that, and we actually provide districts with what’s called a recognised structural cost to try and support them within that space as well. So the model itself has got multiple arms to it, and the whole premise behind the way we have moved is that we keep the system safe and operating. And so we can probably give you a bit more detail ..... 40 DR MITCHELL: So I just sort of remind the table as well, at the moment we’re talking about sort of the Ministry of Health and our role in the funding too, but just taking that step back is that it’s a shared responsibility across government as well. So the question around what’s the share across primary care, for example, is much 45 bigger than - - -


MR KMET: Yes. Same problem applies in primary care. I mean, we’ve got – I mean, if you listen to the numbers, primary care is going great. I mean, bulk billing is up to 85 per cent, we’re seeing more patients than ever before, but actually the kinds of things that – you know, the activity ..... more activity is meaning that you’re getting more money into things that actually are easy to do and less money into 5 continuity of care and responsibility for that person’s life. And I think that’s where these pieces of funding need to come together and be able to create, you know, what do we want this system to look like in terms of funding block and what percentage of that system does that represent, and how do we then deliver it, because I think there’s too many bits effectively arguing for funding in the same silo, and this is just ..... 10 justification industry around more money and more volume. MS WALLACE: I’m just really conscious of wanting to be able to spend probably more time than people have, but as much of the rest of the time - - - 15 THE COMMISSIONER: I’m afraid I have just one question I want to flag - - - UNIDENTIFIED FEMALE: ..... THE COMMISSIONER: - - - but then we will move on quickly. Mary raised an 20 interesting point looking at the KPIs for mental health, with some jealousy I think was the term you used. There’s the Living Well strategic plan in mental health. It’s a 10 year plan, as I understand it. Can I just ask this – if there were a similar 10 year strategic plan for drug and alcohol in New South Wales, would we expect to see more KPIs – would it be likely we would see more KPIs in these agreements with the 25 LHDs? MS WOOD: I think ..... as I said, each year we work extensively over 11 months of trying work out what plans, what strategies are in place, that we need to incorporate into the agreement. I agree with you in terms of what KPIs are in there at the 30 moment they are probably quite immature in terms of where we could get to, and I think there’s a real commitment right across all of our services we started with ..... input type measures to start to move into the outcome space. And that has taken some time. And a lot of that is around making sure we’re capturing the right thing, what are the outcomes, and what outcomes are we looking at? Is it patient ..... 35 outcomes? Some of our actual staff and service delivery outcomes. That can take a bit of time to actually conceptualise. But if there was something planned that was in place that had gone through robust consultation with the sector, with our consumers and everyone, that could clearly identify some key performance indicators for the system, then absolutely the service agreement could accommodate that. 40 THE COMMISSIONER: Thank you. DR MITCHELL: But the other comment that I would make, though, is that the service agreement is the only - - - 45 THE COMMISSIONER: Sure.


MS WOOD: No. DR MITCHELL: - - - place. And so I take you back to the HIV example where we’ve had a couple of KPIs, but that in fact it’s the broader data reporting that we do, which gives much better insight into what’s actually happening across the system 5 and helps determine where we go next. So I think that we always – that will always be the case, I think, that we will have some of the headline indicators in the service level agreement and more detail which sort of gets prosecuted at a different level, and I mean, Mary, you’ve been involved in some of the HIV and blood-borne virus work as well. You could see how we develop over time. So it’s the same model, I 10 think, that we will – it is the same model that we would like to work towards in AOD, but the key thing, I think, for this year, and the key message that I would like to say that for this current financial year, by including the targets around activity, actually is helping us to grow activity across the system, and that’s a very positive thing in this discussion. 15 THE COMMISSIONER: Yes. Over to you. MS WALLACE: I’m going to close the discussion there acknowledging that there will be some further questions coming back to the Ministry in terms – because I think 20 everyone is grappling with understanding the complexity ..... some changes this financial year, understanding what they look like and what they mean and how they add up to the ..... So I’m going to shift now to spending the remainder of our time around the contracts 25 with the non-government sector and what happens with this. And I – it’s important here – I think we want to really make sure we spend as much of the rest of the time we’ve got on what could make it better as opposed to keep, you know, looking at the problems. 30 I will have a go, based on the evidence and the discussion paper, at identifying what I understand to be the key issues with contracting with the non-government sector and then suggest that we move to sort of what would make that work better. So what I read from –and I will ask the Commissioner and Nick to add in terms of anything I’ve missed out – what I’ve read from the evidence and the discussion paper is that 35 there’s an issue about no consistent model for pricing services. So in terms of what a bed is priced at ..... depending on where it’s delivered. The complexity and lack of transparency around the existing funding arrangements. The nature of the contracts. Short term versus longer term, there’s a pretty consistent 40 message around that. The multiple reporting requirements depending on where – even within the same funder, but particularly even more complex when you look across multiple funders. There’s a whole lot of debate about whether CPI is or isn’t included in terms of any – as funding rolls out year on year. And then there was a pretty consistent message about the importance of workforce development and the 45 lack of sufficient funding to enable – particularly for the NGO sector around growing


the workforce. They were the key issues that I picked up. Dan, anything else you wanted to add? MR KELLY: I would say just the consequences of some of those things are probably some of the most powerful evidence that we’ve heard in the regions. 5 THE COMMISSIONER: Yes. MR KELLY: And so the inability of services to plan effectively for the longer term, the tensions around actually being able to find staff in the first place, but then once 10 you do, being able to keep those staff in circumstances where you have no security of tenure for your staff based on the length of contracting, the administrative burden on some really small services like Norm’s service. We had some really powerful evidence from Dubbo about how difficult it is for smaller services to - - - 15 MS WALLACE: For tender. MR KELLY: To tender. I think the evidence that Cate gave is around it being a disincentive to collaboration and cooperation between NGOs, in the sense that they are competing for funding, which means that they’re less likely to share information 20 with each other. That the contracting, the length of contracting, is an issue not just for the service providers but for the PHNs - - - MS JAMES: PHNs - - - 25 MR KELLY: - - - as well - - - MS JAMES: - - - as well, yes. MR KELLY: - - - in the sense that they’re confined by these short timeframes and 30 this short amount of notice. And equally, I think, on the information sharing, that the – one of the powerful things out of the PHN evaluation was that there’s the – not the same level of information sharing at the kind of PHN/LHD level, partly for some of the same reasons. So I think - - - 35 MS JAMES: Yes. THE COMMISSIONER: I’d only add to that – I think Nick has covered virtually everything there – sort of a lack of coordination between funders who are funding particular NGOs. So they’re not - - - 40 MS JAMES: Yes. THE COMMISSIONER: Someone gave the analogy of a house of cards, where - - - 45 MS JAMES: Yes.


THE COMMISSIONER: - - - you’ve got separate little components of a enterprise that’s an NGO are being funded by different bodies; one of them is pulled away; then the enterprise may collapse. And it’s that sort of tenuous existence; it must be horrible for them. I think that’s another issue, too. 5 MS WALLACE: So what are – yes, Alison. PROF RITTER: I just want to make an observation that we’ve just had a conversation about alcohol and other drug treatment funding in LHDs, and now we’re going to have the same conversation about alcohol and other drug funding in 10 NGOs, and both of them provide the same service. MS WALLACE: Yes. Potentially. MR PIERCE: Sorry? 15 PROF RITTER: Potentially? MR PIERCE: Potentially? 20 MS WALLACE: Potentially. PROF RITTER: I mean - - - MS WALLACE: No. 25 PROF RITTER: - - - withdrawal, counselling - - - MR PIERCE: Yes. 30 MS WALLACE: Yes. PROF RITTER: - - - case management, outpatient support. Maybe a specific thing around resi rehab, but - - - 35 MR PIERCE: That’s the only - - - PROF RITTER: - - - basically we have - - - MR PIERCE: - - - thing that’s different, yes. 40 PROF RITTER: We have a system of care with two completely different funding systems. MR PIERCE: Yes. 45


MS WALLACE: Yes. Yes. Walter, and then I do – I want to give plenty of time for the NGOs, guys, so I just – so I’ll go Walter and Michael briefly, and then I want to move across to the - - - MR KMET: So I’ll probably sympathise with everything the NGOs say about – 5 having been a PHN – trying to deal with contracts and structures and formats. And I think it’s basically a function of us trying to deal with things with hundreds of small projects, rather than saying, “Well, what does this continuum of care look like?” You know, “What should this journey look like?” And, “Who are the providers that can come in and be part of one journey, as opposed to having their own separate 10 story?” And that’s no – there’s no greater exemplified than in the issue of data. You know, everyone’s got their own data sets, their own – every – it’s someone else’s consumer, where there should be the system looking after the consumer, with NGOs, public 15 sector, private sector, coming in and dealing with that journey as equals, as opposed to, “I’m letting a contract for this bit,” or, “I’m letting a contract for that bit.” Inevitably, that causes a fragmentation of care. I mean, I think, it’s often difficult to manage. 20 So I think – I think we need to do better as a system in defining what is this journey for a person, regardless of whether it’s public, private or otherwise, and who’s responsible for delivering that journey, and how do – you know – how do all these people fit in to the – delivering that journey, as - - - 25 MS WALLACE: Yes. MR KMET: - - - one – as one outcome, as opposed to a series of individual and separate outcomes. 30 MS WALLACE: Yes, acknowledge that. Michael. DR MOORE: Look, I was going to just tell a story. When we inherited our TPG contracts from – sorry; novated – they were novated across to us – we went and saw all of our providers and had a little chat to them. And one of our providers, bless 35 them, got a bit confused, and – because we said, “Can we have a look at the contract that you got with the Commonwealth,” and they showed us the contract that they had with the LHD. And they were almost the same. Almost the same. The KPIs were almost the same; the amount of money was almost the same. And the question that kind of occurred to me then, and which has occurred to me again now, is, why 40 wouldn’t you just pool them? MS WALLACE: Yes. So there’s obviously some comments about what the system looks like of a whole, and what – why – but, acknowledging that – why wouldn’t you just pool the funding, whatever – I think we just want to make sure that we hear from 45 the NGOs about what, in reality, they would like it to look like. So I’m going to ask Cate, Norm, Mary as well, and Gerard about what you would like. So from an NGO


perspective, what would you like the arrangements to look like – the contracting arrangements to look like? MS HEWETT: Starting with me? 5 MS WALLACE: Go, Cate. You’re on the left; you can go first. MS HEWETT: More of a business model approach. So it did sort of dawn on me that I have a lease with my local area for the building, and it’s a three-by-three-by-three. And I thought, why can’t my funding be like that? Three years by three years 10 by three years, unless I step outside the realms of, you know, not meeting my contract – my agreement; then it’s revoked. But, you know, a review at the end of every three years, and I’ve got nine years. And I’m hesitating to say – every suggestion that I have is probably going to, from here on forward, be something that’s been recommended by somebody else in this book. So it’s not rocket science, 15 but – so three by three by three would be wonderful. And what that has, on impact of the workforce development – not just in me retaining staff, but our sector has an issue with workforce development. So if I train up someone fabulously in my sector, and her role is at risk of being dumped to the 20 side, she’ll jump out of drug and alcohol. Like, she – there’s no – there’s no, you know, safeguard that she’ll end up in drug and alcohol in another service. She might end up in private practice in psychology, and that – we’ve lost a drug and alcohol. So it’s not just my service that could potentially lose staffs by this impact; it’s actually the sector. So it’s hard to develop our workforce without it. So let’s have a 25 longer agreement. I think we need – and I think we have done this to some greater – some level, but a mapping of the service providers, and who does what in the state. We think that might allow us to have a bit more of a conversation around that. We have done it, 30 but we get a lot of funding different – different funding streams. So what is funded by the Health Department – they may not be informed of what’s being funded by the PHN or the Commonwealth, things that have changed or evolved, or a new – if you’re a really dynamic, larger organisation, like the Salvation Army, who’ve generated donations, so they’re offering another funding stream – so there’s things 35 that change; we need to be on top of what service providers are actually delivering. I’m a real advocate – I don’t know if there’s any support for this in our area – of going back to being administered from the state. I’ve already sort of pledged my admiration for the team at New South Wales Health – I sound like, “I really want 40 some more money!” I think they are a really dynamic team, that have the potential to actually deliver a greater relationship with state-wide services. Being a state-wide service, and being administered by the local health district, is a decision that was made really poorly, and it was a historical decision that’s never been really reviewed at the government level, as to why we’ve ended up there and why we’ve stayed there. 45 There’ve been just sort of, like, a factor of convenience. So I’d like to get some


investigation into whether it’s of any benefit for state-wide services to remain where they are, at the LHD. And then, why we have PHN and, you know, different – I have a fabulous electronic platform for my PHN, that I think is – the PHN that I’m in is really dynamic, and 5 engaging with our service, but I have all these different platforms on funding; that’s a problem. The solution, obviously, is streamlining our KPIs. And they all contribute to the same service, in different ways, so they all need the outcomes that the service provides. So it shouldn’t be very difficult to streamline the way that we report. We can all have the information in. 10 And as an NGO, I want to give you everything that I have. On the contrary to “Oh, you have too many KPIs,” I don’t mind giving you a million KPIs, if they’re all the same. Or – not all the same; all different, but the same consistency to our funding providers. It’d be fabulous. I think you need to know the fabulous work that we’re 15 doing, and it’s not being reported adequately through these multiple platforms, with multiple funding providers. Can I just have one second to quickly - - - MS WALLACE: Sure. I’m happy to come back as well, if you - - - 20 MS HEWETT: No, I think that’s pretty much it in a nutshell. MS WALLACE: Great. Norm. MR HENDERSON: Yes. In relation to Aboriginal resi rehabs in particular, the data 25 systems are – most of the rehabs were given a data system that fits more to an AMS or a medical model, and we’ve had trouble adapting to that. And, of course, there’s no money to change, and there’s not enough money to find, to utilise, to build, our own system. So we got a problem right there with the – with the data systems. And it’s been something that’s been happening in Aboriginal resi rehabs for a lot of years 30 now, that each rehab has got a different data system. So what we’re trying to do at the moment is standardise all our stuff in the Aboriginal resi rehabs, which we’re – we’re doing a lot of work with NADA and the AH&MRC in relation to that. But – yes, we’re – like Cate, too, we have multiple funders, and the time spent on 35 doing all those different reports – now, as a CEO of a small organisation, if somebody’s off crook, I might have to jump in and do a shift. You know, that’s just the way it is in those organisations. And we seem to be spending more and more time on reporting complications, and I don’t know. The LHD’s amount of money to us is very small, but I would have doubt, if you just looked at the KPIs, I would have 40 a doubt if they even knew what they were purchasing, if you just looked at the – I don’t know what we’re providing, if you just looked at the KPIs. See, that – and that’s not just in relation to the LHDs either. It goes across all the funders, because I think, too, resi rehabs are sort of out there, 45 right, they’re just the poor cousin, you know, so there’s always been a problem with that. Geographically, too, out in that back country, a lot of the funds go – they’re not


designated for transport, but they have to go on transport. That’s just the way it is out there, you know. You go out to Brewarrina and you’re four hours away from Dubbo, and there’s not too many services in Brewarrina, so the only place you can go is Dubbo, so these are all the things you’re fighting against. Retaining staff in a place like Brewarrina gets very difficult, you know. 5 We sent staff – you’ve got to send them to Sydney to be trained. If you’re lucky, we’ll get – some stuff will come out to Dubbo, we can do some training in Dubbo, but generally – and you’re not going to send staff to Sydney for a one-day training, because there’s three days gone anyway. It’s a day each way, so you wait for two or 10 three days, or we team up with the AH&MRC and we do week blocks in Sydney, that type of thing, but then, when you get them trained up, you know, they head off to another system who can offer them $10,000 a year more than what we can so – and I don’t blame them. That’s just the way it is, so these are the things we work with, you know, and, you know, I think, at the present time, NARHDAN is looking 15 for a 20 per cent increase in resi rehab funding at least, you know. That to me would give us a bit of a level playing field, you know. It’s only a start, but we scrape for everything we can get out in that back country, and, you know, some – the resi rehab that I work with a lot in Cowra takes couples and males and 20 females, so then you’ve got all the added stuff of FACS or DOCS, whatever they’re called – I think they’ve got a new acronym now. UNIDENTIFIED FEMALE: ..... 25 MR HENDERSON: DJ something or – anyway, you’ve got all that added stuff, so your staff have to be multitasked, multi-skilled at domestic violence, drug and alcohol, mental health. We get all fellas. We get the fellas that no one else wants, so, yes, it’s a real tricky environment to be in, when you’re looking at money-wise, and then wonderful things happen, like you can’t purchase vehicles any more. 30 You’ve got to lease them, you know. You’re looking at just $1200 a month for a lease vehicle, that type of thing where, out in that back country, the money is not there to do that, and - - - THE COMMISSIONER: I’ve heard so much evidence in this inquiry from NGOs 35 saying that they have had staff who have had to, you know, work overtime without pay, under extraordinary circumstances, driving people long distances out of hours. MR HENDERSON: Yes. 40 THE COMMISSIONER: And it’s just the passion that they have, but that burns out after a while, and I don’t think this has been recognised enough in what’s being offered by way of remuneration or funding, I should say, to NGOs. That’s an impression I have. I haven’t come to a fixed conclusion about that, but I’ve heard a lot of evidence about that, and it’s distressing. It’s very distressing, because we’re 45 not building up a workforce, and a workforce needs people who can mentor new people coming into it. You need an updraft of quality to maintain quality, and it


sounds to me like people are coming and going because there’s something better somewhere else, and this is an area that people are passionate about and can be passionate about, and I think that needs to be recognised. MR HENDERSON: Having said that, too, it’s also an area where people stay for 5 long periods of time. People in the resi rehabs that I’m in, there’s a lot of people are eight, 10, 11 years in the same – but because of that passion you’re talking about. THE COMMISSIONER: Yes. 10 MR HENDERSON: That’s why they stay there. THE COMMISSIONER: Yes, yes. MR HENDERSON: You know, I – if I didn’t have that passion, I wouldn’t be 15 jumping in my car every other week and heading out to Lightning Ridge and Walgett or Bourke, you know. That’s the type of thing that – and I think there’s an expectation that that’s just what you do, and over the years, I think, CEOs right through to the staff in resi rehabs particularly just make do. This is what we’ve got. We just make do with it, and we do a little bit extra, and we’re hoping that that will 20 be recognised, but it’s not, so you just keep doing that little bit extra. MS WALLACE: There’s a strong message there, too, about recognising what it actually costs to deliver a service, depending on - - - 25 MR HENDERSON: Yes. MS WALLACE: - - - where you are, and the importance about what you’ve got to build in, and I’m sure we’ll hear from Gerard as well about just the cost of – you’ve done a bit of estimate of cost of administration as well, but, Norm, from you too, 30 consistent message about sort of streamlining the ..... getting the right data systems, which makes it easier for you. Mary, for you, what should it look like? DR HARROD: I guess I’ll just talk about our specific contract, but I think it has points that both Norm and Kate have raised. So we’re funded under, as I said before, 35 hepatitis C money, so prevention and trying to get people into treatment, but people are not that necessarily interested in hepatitis C treatment. Like, you can’t – you know, it’s a person that we deal with, and I think that, you know, we – we – the people that come to us and the people we work with are people with complex lives and problems and issues, and then reducing them to a particular KPI or condition or, 40 you know, it is very – it’s difficult for us, because we have all the same, you know, drivers as the other people at the table from NGO services, which is kind of a love of community driving us, and you can’t sort of – you know, the thing that Kate said that really resonated with me is she wants more KPIs, because we – like, a lot of the work isn’t recognised, and it isn’t funded, and it does kind of take a toll on staff to do it, 45 and I think that’s, like, a really good observation.


I guess the point that was made earlier by Walter around data, you know, we do have the My Health Record, but, you know, we actually advocated against the My Health Record or for people to be very, very cautious in taking it up because of the stigma involved in having AOD issues, and, you know, we have a new document coming out, a consumer guide to opioid treatment, and there’s a section on the My Health 5 Record which is very cautionary about having that, you know, because as much as it would be fantastic for a period with drug and alcohol issues to go into an emergency department and be cared for appropriately – and maybe we just hear the bad news, you know, maybe, like, lots of people go in and it’s all good, but, yes, we do hear the bad news. 10 The bit about state-wide services is under LHDs is, you know, so the main mechanism for people to access treatment, the Alcohol and Drug Information Service Line, you know, we know that there’s issues with it. It’s sitting under an LHD. The scrutiny is of that – those kinds of services is not particularly good, so we have these 15 things that are kind of trapped in these old funding contracts and that – it just doesn’t make sense for a state-wide Alcohol and Drug Information Service to be sitting in an LHD, you know, and we’re now, an organisation that is not at all funded for it, are getting referrals from one of those state-wide services. We can’t help you ring NUAA, and it’s like, “Okay.” Yes, that’s all I would say. 20 MS WALLACE: Yes. Thanks very much. THE COMMISSIONER: Is the LHD that you are placed in determined by, what, your registered office or – is that what it is? 25 DR HARROD: Yes, we’re not really affiliated with an LHD, so we – our building is kind of provided by the state. It’s subsidised by it. THE COMMISSIONER: Right. 30 DR HARROD: And our needle and syringe program is within an LHD facility but the data for it is counted independently, so – but it – but we – it’s very hard for us to provide a genuinely state-wide service. Like, we don’t have the ..... to do that. 35 THE COMMISSIONER: But generally speaking, a state-wide service such as Cate’s, your LHD is determined by - - - MS HEWETT: Physical location - - - 40 THE COMMISSIONER: The physical location of your office, yes. MS HEWETT: - - - of the service, yes, yes. THE COMMISSIONER: Okay. 45 MR PIERCE: It’s called hosting.


THE COMMISSIONER: Hosting. MR PIERCE: That’s what it was called initially, yes. THE COMMISSIONER: Right. Okay. Thank you. 5 MS WALLACE: Gerard, so what should it look like? MR BYRNE: Well, first up, I just want to kind of dispel the myth of the large NGO where there’s rivers of money - - - 10 MS WALLACE: With lots of money. MR BYRNE: - - - and rivers of resources. 15 UNIDENTIFIED FEMALE: Sorry. Sorry, Gerard. MR BYRNE: Each department in the Salvation Army, each social service department has its fixed budget, and it’s serviced within each department as its fixed budget and needs to operate within that and stand on its own merits or it falls. That’s 20 how it is. And in our case, we’re having a little bit of a fall. So in New South Wales we currently provide around 240 residential treatment beds. That’s going to be reduced by 75 by 1 January 2020 because the funds just aren’t there to sustain them any longer, internal Salvation Army funding. Currently, if we were kind of to divide our external funding across our beds, and we’re funded at the rate of about $40 a day 25 per bed, and we just cannot maintain it any longer, so there’s going to be a reduction. We’ve made that decision. The biggest service that’s going to be hit by that is the Dooralong service up on the central coast. So we’re already in the planning processes for that. We’ve also 30 looked at the projections of the impact of the loss of the SACS ERO on the increased wage scale post-December 2020, and we’re looking at the reductions that we need to make in staffing at that point to stay within our fixed budgets. Of course, reductions in staffing also means a diminution in the amount of service that we’re able to provide, so there will be less treatment places available, you know, within Salvation 35 Army services post-December 2020 because of the impact of that. Additionally, in relation to the SACS increase which, as an organisation, we actually supported and are appreciative of the ERO payments that we used to get, given that whether it’s State or federal funding, both grant streams were really only partial funding streams for our services and we carried a lot of staff where we actually weren’t paying the 40 SACS increase from Salvation Army funds. Again, that now has entered a point where that’s not sustainable on an ongoing basis, so that’s further going to impact post-December 2020, and the reason for that is that, you know, our main fundraising event, which is the Red Shield Appeal each year, 45 you know, that’s seeing, you know, gradual reductions, particularly coming off the back of the GFC, but not only because of that but because of natural disasters and


there’s a sense in which there’s, you know, a little bit of, you know, fatigue out in the community about donations because this seems to be something happening all the time. As far as tendering is concerned, you know, we don’t have tender teams. We don’t operate where we’ve got one sitting on the shelf and a tender has come out; let’s pull the tender team out and do it. We pull together people from services. So 5 other people backfill and pick up their lot, you know. We do our best. Some of those are extremely onerous, you know, because when we look at funding we need to look at the front end of that as well, and we got to a point two or three years ago where basically if your funding agreement didn’t look – funding 10 application didn’t look like a dissertation then, you know, you were probably up against it, you know. They have simplified somewhat over the last year or so but still far too complex. And I often wonder, you know, whether there’s capacity to assess multiple ones of those in the room on the day, given the volume of information that’s provided and if actually what an agency has tendered up to apply 15 for actually gets the mark or whether the way in which tenders are assessed pick that up or not or whether it’s just about the quality of the documentation. Just something I wonder. In relation to the actual funding agreements that we manage and report on, you 20 know, we have a situation where we have this treatment place funded by the Commonwealth and that treatment place funded by the State. We’re delivering the same service to both but we have different reporting requirements, and we’re reporting on different outcomes, which brings me to my next point in terms of grant management is what is the actual outcome. You know, if it’s about people being off 25 drugs or alcohol or, in this case, ice, you know, well, we’ve got 240 people today who are off, so 100 per cent success for our funding. Thank you. But the thing is, it’s not about that. It’s general health, mental health, dental health, housing, employment. 30 Our drug and alcohol case workers now have become liaison officers with the Federal Government Department of Jobs as we liaise with them in relation to the job network providers who have a huge say over whether someone can access drug and alcohol treatment or not. The impact on that is huge. We had 11 people at one of our services kicked off their benefits for non-compliance with their job-seeking 35 activity, even though they were already in treatment. So we eventually got it sorted out but that’s the sort of thing that we’re having to deal with in relation to the clash between, you know, Federal Government requirements over the Centrelink benefit for the resident and also their need to access treatment. 40 That’s an ongoing issue, and I think, you know, like everything else, you know, we could be working in one area where we have a really good relationship with the job network provider and things go smoothly, and then you can have another area where they’re not. And then if that worker leaves and they’re replaced by someone else who has a different understanding of the manual that they’re given, then, of course, 45 that disrupts everything that happens. In general terms, at the LHD level, we have very good relationships with the drug and alcohol people and also with the grant


management people. That’s good. I agree with Cate about the confusion between being hosted within the context of an LHD but providing a state-wide service, and certainly notice a difference between being centrally managed and being managed individually from LHDs. Our services in Queensland, they’re all centrally managed and it’s a much smoother, much consistent process across the State. 5 Also, having to have multiple income streams from multiple funders as well as what we call Salvation Army support funding, which is the Red Shield Appeal funding, having to have those come in and build up a business model doesn’t really let you project longer term in relation to the growth of your business. I’ve said earlier on in 10 the day that, you know, most businesses are doing their business projections five and 10 years hence, and we’re not in a capacity where we can do that because we don’t know what the funding is going to look like. And when we do project, we project around three years ahead, and what we’re seeing is actually a reduction in income which needs to drive a diminution and the level of service delivery that, as an 15 organisation, we’re able to provide. So stronger surety in the longer term. Cate was mentioning, you know, three by three by three. MS WALLACE: Yes. 20 MR BYRNE: And within the context of all contracts are those get-out clause anyway, you know, which allow a funder to, you know, express their dissatisfaction and to cease the arrangement. That would require, you know, I guess, some sort of political will to move to that level. The other thing, and I mentioned this earlier on, is that we don’t – we don’t get attention or finding in drug and alcohol unless there’s 25 a crisis. And I guess the Commission is an example of that as well, as was the Federal Government’s senate inquiry into methamphetamine, as was the recent review of access to residential service – rehabilitation services for rural and remote New South Wales. So it’s not until there’s a crisis. So if we, as a sector, are responding to crisis all the time, we are always going to be chasing our tail. 30 MS WALLACE: Yes. MR BYRNE: Always. Because we’re never proactively building business and we’re never proactively identifying the need as it grows and developing the service 35 to be there when that need is there, because we’ll always be behind in relation to how we do our business. MS WALLACE: Thank you. 40 THE COMMISSIONER: Gerard, can I ask in relation to your Queensland operations which are centrally managed, is that in the Health Department there or - - - MR BYRNE: Yes. 45 THE COMMISSIONER: It is. Okay.


MR BYRNE: Yes. THE COMMISSIONER: Right. And it works better? MR BYRNE: Yes. 5 THE COMMISSIONER: Yes. Good. MS WALLACE: That’s consistent messages about streamlining of those. It’s the number of people you have to deal with, the number of funding pools you have to 10 have, the number of different reports you’ve got to prepare. All of that is about, sort of, adding extra complexity into the way - - - MR BYRNE: Yes. 15 MS WALLACE: - - - you’re operating. MR BYRNE: Yes. MS WALLACE: Yes. Yes. Could I just – just to make sure that we’d clarified for 20 the record the SACS ERO sort of enhancement. So who – what’s the funding source for that? Was the Commonwealth or State funding for that? MR PIERCE: Both. Sorry. 25 MS WALLACE: No. MR PIERCE: So the State Government is committing to rolling the ERO supplemental payments into the base grant of the NGOs they fund where the state treasury provided the Health Department the supplemental enhancement. That will 30 be – it’s the Commonwealth that’s not doing it. MS WALLACE: Right. Okay. MR BYRNE: So in relation to, you know, our financial risk management as an 35 organisation, we can’t take an intention and build it into our budget. MS WALLACE: Yes. MR BYRNE: All we can take is what we know we have and, until we know we 40 have it, we cannot build it into our budget. So, you know, the financial risk management framework, the Salvation Army won’t allow that to be considered. MS WALLACE: Yeah. 45 MR BYRNE: It notes it, but it doesn’t allow it to be considered. Secondly, as I said, you know, with the State Government and the Federal Government being part


funders, there’s a significant amount of our staff salaries where the increase has been unfunded since the SACS ERO – the SACS award was increased, sorry. Yeah. MS WALLACE: Because that’s what you’re funding from your fundraised funds and you’re paying the SACS award as well. 5 MR BYRNE: Exactly. Yeah. And the impact of that is financial pressure on our drug and alcohol services and the decision being made to reduce service provision in New South Wales. 10 MS WALLACE: Yeah. Larry, I just wonder whether you wanted to make any additional comments in terms of what it should like in terms of contracting for NGOs because we’ve certainly heard from the providers here about what they would rather see. But anything in addition? 15 MR PIERCE: Well, I’d echo all of those things. I think that the thing that needs to happen with the NGO grant program, well, the NGO drug and alcohol budget now, which is made up of a whole lot of bolt-ons plus the original grant contribution, and what has never happened with that budget is that it’s never been reviewed in terms of the cost base of service provision that the NGOs under contract actually have. The 20 contribution has always remained that so the state is only providing a contribution of a portion. There are some direct contracting arrangements for – and unit price purchasing through things like diversion programs. MERIT would be one of them. But by and large that’s – and some elements of the drug package you mentioned before. So I think there needs to be a complete review of the NGO budget and it 25 needs to be – and we have provided you the papers about that. MS WALLACE: Yes. MR PIERCE: And we’ve suggested the amount of money that needs to go into it. I 30 think, on top of that, as Cate suggested, and I think Norm and both Marys said, about KPIs, the only thing I would say is we actually don’t need more. We need the ones that we’ve already got to be reviewed so that they’re value-based. So we move away from counting bums on beds and how many people are pissing into cups and how many are doing this, that or the other or going to a group and do some value-based 35 KPI planning. So what is it that’s improved for the client, and there are a number of outcomes, measures, that organisations like Cate’s and Norm’s and Gerard’s use. And I would also agree with the rolling renewal three-year contract, although I can’t see why it shouldn’t be a four-year – rolling four-year contract, given the state budget is a four-year budget process. And that applies to – Health applies that to the 40 hospital in the LHD section. It should also apply to the NGO program at works. We reject the notion that there needs to be any more contestability within the current NGO specialist program that the Department of – that the Ministry of Health funds because it’s been contested and contested and contested since about the late 1990s. 45 So there’s not a lot of new players who’ve moved in. There has been some mergers and amalgamations across the sector but, by and large, it’s a relatively stable, high –


fairly high-functioning NGO program sector, so we should move away from the notion of re-contestability every three years to a program, as Cate mentioned, where – tied in with your appropriate performance reporting, which moves away from volume to value, as the ministry likes to say, which we fully agree with, that we move to that stability in funding, based on appropriate performance. 5 I must say, our work with my colleagues in the Ministry around that stuff is progressing really well. We are doing a lot of work around common core KPI sets. There’s a set of five now common to everybody. We need to do – we’re moving towards the next step now with outcomes-based KPIs which we can provide across in 10 a standardised way. Then there would be room for some additional specialist sector – or specialist population groups within the service delivery of the sector to capture those as well. But at least we would have some kind of clarity and meaningfulness with the reporting environment. Again, it was nice hearing that LHDs do a lot of work with the internal reports that they’re getting through the service level 15 agreements. That would be nice if that happened for the NGOs that provide that data through to the LHDs now because, by and large, unless there’s – I only know of a few examples where those KPIs and the data from those KPI reports is actually used by the LHD 20 contract compliance people for anything. I think that’s because there’s been a history with the NGO program of focusing on compliance rather than on good performance management, and I think that’s a cultural shift that needs to happen as well. So they would be the main. 25 MS WALLACE: Yes. Elizabeth, I think you wanted to make - - - MS WOOD: Just one minor thing. I agree, in terms of the length of contracts, it is much easier in terms of managing services of that nature. The challenge we have is that we actually negotiate our budget with Treasury annually. 30 MR PIERCE: Okay. MS WOOD: So it’s not on a four-year cycle. 35 MR PIERCE: Right. MS WOOD: So I just needed to be clear on that. DR MOORE: So how do you run your hospitals? 40 MS WOOD: I beg your pardon? DR MOORE: Do you have annual budgets for hospitals or do you - - - 45 MS WOOD: It’s an annual process.


DR MOORE: So every year, come 20 June, you don’t know if you’re going to get any money on 1 July? Is that how you run hospitals? I’m just curious to know. MS WOOD: So in terms of the funding-wise, as I said, it might be worth at some stage if you want to go back through the funding approach because we haven’t really 5 gone through the actual modelling of it. It is a 12-month process. We develop a funding model and purchasing model with each district and network based on what their actual activity profile will look like for the following year. So it’s 80 per cent population driven. We take into account the health needs index and there’s no relative utilisation. We then work out what that profile looks like across all the 10 activity streams for the coming year. So we work – so we don’t have a blanket approach to all districts and networks. It’s an individual conversation with each of them. But we do not know until budget day what the actual budget - - - DR MOORE: You understand the point I’m trying to make, though. 15 MS WALLACE: Yes. MS WOOD: I appreciate it fully. Yeah. I guess it’s just something that we’re all in a similar - - - 20 MR PIERCE: Well, we are because - - - DR MOORE: But I don’t know if you are - - - 25 MR PIERCE: - - - LHD staff aren’t on one-year contracts. MS WOOD: Well, they are. They still have a service agreement every year. MR PIERCE: But LHD – so all the doctors and nurses are on a one-year 30 employment contract? MS WOOD: I see what – I apologise. No, no. That is not - - - MR PIERCE: That’s what happens. 35 PROF RITTER: And it’s not competitively driven. MR PIERCE: Yeah. That’s what happens in NGO land so - - - 40 MS WOOD: No. DR MOORE: So what happens with the NGOs is they don’t have a contract six months out that hasn’t been renewed, their staff start to leave. 45 MS WOOD: No, we can appreciate that. I’m just trying to - - -


DR MOORE: So that’s a completely different situation to what the hospital system is like. MS WOOD: No, no. I just wanted to be clear that, in terms of our discussions and negotiations with Treasury, they are annual. It’s not a four-year process. 5 DR MOORE: But in terms of your discussion with your staff, though, it’s quite different. PROF RITTER: Of course. Yeah, very different. 10 MS WOOD: And I appreciate that. I’m not disputing that in any way. PROF RITTER: Yeah, yeah. 15 MS WOOD: I just want it to be clear that it’s not a four-year cycle. DR MOORE: I can’t emphasise this point enough, you know, in that the hospital system is run one way and the NGO sector is treated – how could I say this – in a stigmatised way. They’re NGO staff. It doesn’t matter if they get sacked. It doesn’t 20 matter that they don’t have continuity of service. It doesn’t matter if they can’t pay their mortgages. Somehow they’re a lesser class citizen than a public employee. That’s what it appears to be. I know it’s not your fault but I just have to make this statement. That’s what I’ve observed. 25 MS WOOD: Yeah. And I think to answer, if I could, in terms of that initial discussion we had this morning and looking at exactly who is providing what in that space and moving forward, how we can do that in a more coordinated approach and being clear whose roles and responsibilities are, maybe that will assist with that, but I appreciate your point entirely. 30 DR MOORE: Yeah. MS WALLACE: And in this – I want to go to Cate, too, because she wants to make a comment, but in this last conversation we’ve primarily also just been talking about 35 the New South Wales Health contracting of NGOs, and then you start adding in the bigger picture - - - DR MOORE: Yeah, yeah, yeah. 40 MS WALLACE: - - - in terms of what that looks like and it adds to that as well. So, Cate. MS HEWETT: First, my sincere apologies to Gerard because, always an optimist, I’m looking at service mapping as growing the sector and it’s actually not, and he’s 45 painted that picture vividly for us, that it’s a reduction to 50 per cent at Dooralong.


MR BYRNE: Yeah. MS HEWETT: That’s going to impact upon my service because I’m in the same LHD as him. So it’s actually service mapping and looking at what you haven’t got that you had the year before, not what you might have now versus what you had 5 before. Scaling up of services is something that I would really like to see. We were fortunate to receive the augmentation funding. That was really well documented through this whole process as well. But if there is new money in the sector, how can we scale up existing services that have produced fabulous outcomes and met all their performance agreements? 10 That should be something that’s considered in this environment that we have, and I’m sure, if we were to make comparisons, it’s very difficult. Do we have apples and apples or do we have lemons and oranges? If we were to look at the government sector, and how that they’re funded – if a hospital grows, a hospital grows. NGO 15 services have to compete against each other, and try and grasp at whatever money is thrown our way. And it’s – yes – it doesn’t promote cohesiveness in our sector at all. MS WALLACE: Jo. 20 DR MITCHELL: So I’d just, sort of – I mean – I mean, clearly, the issue of certainty and stability is a really important one, as well, and we recognise that. And we have moved to three-year agreements with our ministerially approved grants. That’s only just coming into being. So certainly acknowledge that the one-year contract, which I think is still the case for – in some services, but not New South 25 Wales Health funded ones, is difficult. So within the New South Wales Health Procurement Guidelines, a Minister will not even – within our guidelines, a ministerial grant is for three years, and we also fund a program grant, which is also a three-year contract. So that’s the – that’s – they’re the rules within which we are operating. And we either need a ministerial or secretary-level approval for both 30 ministerially approved grants as well as program grants. I think that there are some process improvements. And including – turning to the three-year contract. And one of the things that we’ve started to look at and recognise that there’s a lot of opportunity to help streamline is that, where we do fund multiple 35 services, that we look to consolidate contracts. And so we have been, slowly, working towards reducing the number of contracts for services that we – that we fund. And I think that there’s more of a better opportunity for us to do that as well. We also have some contract timing issues, as well. So if you’re funded under a 40 particular program of work and another one, the contract timelines don’t always turn – they don’t always align. And so, you know, the issue that you raise, Cate, about looking forward into your budget is one of those examples of where, you know, one of your streams of funding from the - - - 45 MS HEWETT: Yes.


DR MITCHELL: - - - ministry is actually – because it ends at a particular time, and so isn’t actually counted in that. So that’s the next step for us, as well, is to look at how we can align those timeframes, so that it’s one timeframe rather than different ones, as well. So – I mean, these are process issues, but I think there are things that we can actually – that can make a difference. 5 And I think the other thing that I’d mention, too, having been involved in the roll-out of the government commitment to – well, the drug package commitment – is that it’s also, on reflection, an important thing for us to think about the way in which we scale up new services, because it does take time for services to get funding, and then to get 10 it to the point where you’re actually seeing clients as well. So there’s a bit of a time lag that we need to be building into the contracts, as well. So I think, they’re very practical examples, within the current environment, that, I think, could – and that we are working through, that has the potential to make some difference there, too. 15 MS WALLACE: Michael. DR MOORE: So – look, a very quick point, which I think has already been made before, but I think it needs emphasising: the Commonwealth is moving to three-year rolling contracts, which means that you get a contract for three years every year. 20 MS WALLACE: Yes. DR MOORE: So that you always have a funding horizon of three years, so you can always offer new staff a three-year contract. So if it’s the last six months of your 25 three-year contract, you don’t just give them a six-month contract; you can still give them a three-year. It’s a - - - MS WALLACE: Yes. 30 DR MOORE: - - - rolling contract. I just – I mean, it sounds really obvious, and I hate to labour it, but I – it would be awful if we didn’t miss this opportunity to move in that direction. MS WALLACE: Yes. Yes. 35 MS JAMES: I’d just like to talk about the funding from PHN, and also recognise, PHN paying into the AOD sector is really, really quite small compared to the state. DR MOORE: Six per cent. 40 MS WALLACE: Yes. MS JAMES: Yes, it’s absolutely tiny, but there’s so much focus on the PHNs. And I’m first to admit, I’m fairly new to the PHN sector. I’ve been in NGO world for 32 45 years. However, you know, coming into the PHN world, and especially the AOD contracts and the various small ..... my first role was to look at how we actually


contract the AOD sector around that. And the first thing is, it’s not just the AOD sector, but the mental health sector. From mental health, we’re going for co-design. And this particular – this vast tranche of contracts, 2019 and 2020 and three years ahead – so we’ve actually worked with our providers around defining the health outcomes and health equities first, and first and foremost. We’re trying to eliminate 5 service duplication and waste, and that’s – you know, we’ve talked about the North Coast Collective – that’s - - - MS WALLACE: Yes. 10 MS JAMES: - - - still in development. However, now, we’re actually still – we’re working towards that now, within our PHN. We also really want to build the workforce, because we actually recognise that we can roll out programs, but if we don’t have a skilled AOD workforce, we’re not going to have an AOD sector, and the health burden and the economic burden on the state and the Commonwealth is 15 going to be really, really significant. So we have to – we have a responsibility as funders – to build that workforce and to support it. And we have to also support the role and experience of clients, carers and families within our funding. So part of our KPIs is – that we’re talking to our providers about 20 – is about the experience of service, not just for the consumer, but how does the families and supporters of those families and carers feel about the service that they’re receiving in the AOD sector? Can I say, the providers that I’m dealing with in the last six weeks, going around, meeting all of these – they’re just saying, “Hallelujah! This is fantastic.” 25 And we’re also trying to move and align our five KPIs to the LHD. You know, because there’s such duplication of KPI reporting, which is really important, to make sure that it is outcome-focused; client-centred, first and foremost; and not duplicative. And the Commonwealth has actually recognised that there are some 30 AOD services that are actually co-funded by the LHD and with the Commonwealth. So those that are co-funded for the same program, that they only have to report into one database, so it’s either the AIHW ATOPS database, or, if they’re purely funded by the PHN, they go to the PHCMDS database. So there is a lot of work around that, but it’s – I would still like to emphasise, PHNs only fund a tiny amount. But the co-35 design focus is really strong. MS WALLACE: I’m going to go to – I’m going to lift us up and go to one of the questions we wanted to have answered, which is, is it possible to have an agreed model between the Commonwealth and New South Wales Government for 40 contracting arrangements, unit prices, contestability approaches and performance reporting? So - - - DR MOORE: So the short answer is yes. 45 MS WALLACE: - - - is it possible?


MR PIERCE: Well, I’m sure the answer is yes, too, but there would need to be some reform, at the – at the Federal governance mechanism level, for the National Drug Strategy, to do that, and there would need to be some leadership at that level, I would imagine. And there’s no reason why the – what’s replaced the IGCD? The National - - - 5 MS WALLACE: NDSC. MR PIERCE: - - - Drug Strategy Committee, yes – should be able to progress an agenda like the harmonisation of contract reporting, and the better information 10 sharing between the Federal and State Health Departments about the same NGOs that they’re both funding. THE COMMISSIONER: Yes. And is – just a follow-up question, and probably to Alison – is the new national treatment framework an appropriate lever to do that, or 15 not? PROF RITTER: It certainly has sufficient content in there to enable that to happen. I would note that we recommended, in 2014, that the Commonwealth give the money to the states – their investment to the states – and the states disburse it on behalf of 20 the Commonwealth. And that would solve a whole heap of problems. MS WALLACE: Yes. PROF RITTER: And that option in theory still exists. 25 MS WALLACE: Yes. Thank you. Gerard. MR BYRNE: So I agree the answer to that is yes, but my supplementary question is, like, well, why hasn’t it happened? Because this isn’t the first time that’s been, 30 you know, raised. It’s been getting raised for years and years and years. So maybe the answer to it is no, because there’s just not the will to make it happen. MS WALLACE: Yes. Walter. 35 MR KMET: I think the answer is yes, but there is a question before that: what are we contracting for? And I think there needs to be a question around, what are we trying to achieve as one funder, as opposed to five or six different funders. And I think, if you answer that – if you begin to answer that question a cohesive way, then, of course, the answer is yes, but then you’ve got – you’re getting away from this 40 thing that Cate raised, around this lack of cohesiveness, which you’re actually contributing to by having, you know, everyone bid for their little bit of a disconnected pie. I think, the other thing is that – you know, I might be unpopular here with the LHD people here – but I’m not sure that that is – it is appropriate to go through the state. I think, if it goes through the state, it needs to be with a framework 45 of a tripartite agreement - - -


MS WALLACE: Yes, sure. MR KMET: - - - between the sector, the PHNs and the Commonwealth, around how money is spent, because it – there is – there is competition of service – a service provider versus a funder there, and I think we need to be conscious of that. And I 5 also think we need to – and, you know, certainly with my days in the Aboriginal space in Western Sydney, I mean, I argued strongly that actually all money to do with Aboriginal health should go into a pot to deal with a common view around how we deal with Aboriginal Health in Western Sydney, not to fund existing and, you know, predetermined organisational structures, whether they’ve got to do with me or 10 whether they’ve got to do with the LHD or whatever else. I mean, we should be actually putting that money into a common co-commissioning pool, taking away from structures that actually absorb duplicated effort, which is exactly what they were doing. 15 So I think to start the conversation needs to be what are we trying to achieve as one continuing care? What are we achieving – what we’re trying to achieve is one strategic outcome, and then everyone should be committed to saying, “Well, actually, you know what, we put the money and put the metrics in and put the contracts in consistently.” But that’s got to be the starting point. 20 MS WALLACE: So we’re sort of looped around to the start of the day - - - MR KMET: Yes. 25 MS WALLACE: - - - where we were talking about - - - MR KMET: I’m sorry. MS WALLACE: No, no, no, it’s entirely appropriate where we – where it’s – you 30 know, where we talked about the importance of having a consistent state-wide view of how you - - - MR KMET: Yes. 35 MS WALLACE: - - - deliver the services, you know, lined up to the Commonwealth, lined up locally. MR KMET: Yes. And so we had this in Their Futures Matter in Western Sydney. 40 MS WALLACE: Yes. Yes. MR KMET: Where we had a service delivery reform group and, effectively, what was happening in that group was we had the contestability framework, which is here. 45 MS WALLACE: Yes.


MR KMET: But actually, people are arguing for more FTEs in their own part of the picture, saying, “We’ve done this before. You know, we can do it better.” MS WALLACE: Yes. 5 MR KMET: “Just give me one more FTE or two more.” MS WALLACE: Yes. MR KMET: So we ended up going back to this thing where we were funding 10 structures. MS WALLACE: Yes. MR KMET: We were actually competing against ourselves and, indeed, we weren’t 15 achieving – well, we were actually doing exactly what Cate says; we were reducing cohesiveness. MS WALLACE: Yes. Yes. Dan, is there anything else? I’m just conscious about time and I just want to keep making sure that we’ve explored all the issues we want 20 to explore. There are other aspects of this issue of contracts with non-government services that you wanted to explore that we haven’t covered. THE COMMISSIONER: Look, I think we’ve covered things pretty well. Thank you, Leanne. What is the time? 25 MS WALLACE: We’re just coming up to nearly 3.30. THE COMMISSIONER: So we probably ought to - - - 30 MS WALLACE: So we said we’d – yes. THE COMMISSIONER: - - - have the last round of each person, then we’ve got to wrap up. 35 MS WALLACE: Yes, we certainly do. So that’ll – yes. So I might do that now. So what we wanted to do now was, having reflected on the journey that we’ve been through today, so we started today around thinking about how you would effectively plan for delivery of alcohol and other drug services at both a state-wide and local level. We’ve explored the importance of the data model, whether it’s DASP or, you 40 know – and all the other data that you bring to bear in terms of planning for services, and we’ve had a conversation about the service agreements and how they work and the KPIs and activity based funding, which obviously there will be further information provided about, and then we’ve importantly had a discussion about what the challenges are in being an NGO delivering services in the framework that it is at 45 the moment and what it should look like.


So I’m going to go around the table now and it’s really an opportunity for everyone. If there’s something that you want to make sure that you will either reinforce or that you, on reflection, though hasn’t been raised, this is your chance to do that as we go around the table. So I’m going to go left, so Cate. 5 MS HEWETT: First again? I probably am not convinced that there’s some solutions to addressing unmet demand, and as a service provider, that’s one of my biggest concerns is that, as a service provider actually funded quite well to deliver the service that’s in my funding agreement, I’m not funded well to deliver the service that’s being requested from the community. I can’t do it. So I feel like I still am, at 10 the end of the day, a bit short on what the solution is to report on unmet demand effectively in a way that it can be further investigated and addressed. MS WALLACE: And that certainly came up, didn’t it, in the conversation about understanding, sort of, what services are being delivered now but, you know, what’s 15 the gap between those services and what’s that going to look like over time. MS HEWETT: Yes. We’re well positioned as NGOs in the community to monitor that for the government. 20 MS WALLACE: Yes. Yes. MS HEWETT: So I would, you know, suggest that you use this resource that you have – us – to monitor and report on that. 25 MS WALLACE: Yes. That’s great. Norm, for you? MR HENDERSON: Yes. Yes. What I said in the beginning is it’s become pretty clear to me that it needs to be from the ground up. 30 MS WALLACE: Yes. MR HENDERSON: Community needs to be a lot more involved in what decisions are being made. 35 MS WALLACE: Yes. MR HENDERSON: And from the discussions here, to me, it’s not rocket science. It just needs to be simple and just go about it in a better way than what we’ve been going about it. 40 MS WALLACE: Yes. Yes. Thank you. Mary? DR HARROD: Yes, it’s been a great discussion. I guess I’m still concerned that there is those people that we might miss in this discussion and that we need to really 45 think about getting people ready to access treatment, you know. So there’s certain opportunities that, like, when you’re pregnant, for example, that you’re really


probably primed for accessing treatment but then there’s a lot of people out there that, you know, because of the stigma that’s, like, rife through the system are very, very wary of it, and how do we engage and reach those people, I think, is a really pertinent question that I’m not sure that we’ve really addressed. But I think there’s ways in everything we’ve discussed. Like, you know, the LHD discussions really 5 illustrated that, but I think that that needs to be a focus as well. THE COMMISSIONER: Do you think that there should be funding for awareness campaigns or, you know, well done ones, well targeted ones to diminish the stigma of drug users? 10 DR HARROD: I think you need a few different things. Like, I think that this is probably a bigger question than I could answer right now. I think that, like, from my point of view, an awareness campaign could be good as long as it’s not like Stoner Sloths mark 2, and the – we’d have to undo all the previous campaigns. But the 15 other thing that we need to do is empower people to demand their rights to appropriate services, which people are very, very disempowered and, you know, I see that just so continuously is people complain but they – like, they won’t access the mechanisms to, you know, formally complain to actually change the system because they’ve been treated so very badly by it. And I think that there’s a piece of, like, 20 raising the community up to empower them to demand, like, appropriate services that we also – like, an awareness campaign, great, but part of the – only part of the solution. THE COMMISSIONER: Yes. 25 DR HARROD: And I guess the other thing we didn’t mention – sorry, I’m taking up more than my time – is that in that funding discussion is that people providing services are also highly stigmatised, and that that’s another thing that we don’t necessarily talk about that much. 30 MS WALLACE: Stewart? MR DOWRICK: Just a couple of things. Again, I’ll just go back to Elizabeth’s point earlier. I mean, the system has moved a long way the performance framework 35 we do have in place. So over the last eight, nine years we really have moved a long way from where we were. So by far and away not perfect but it’s come along way, and the whole ABF concept and, you know, I’m in a district that actually generally exceeds its activity targets, and putting more funding into that non-acute area over time. So it has taken place but it’s hard work, so it’s not easy, you know. It’s tough. 40 I don’t think – personally, I didn’t hear a lot about Aboriginal health from the group. And I might’ve missed some, sorry ..... but I just didn’t hear a lot. We’ve got wonderful AMSs in the mid-north coast but when we tried to start a few years ago something similar to the North Coast collective, we called it an Aboriginal Health 45 Core – a similar concept of let’s all get together and see what we’re all spending in – on Indigenous health. It was just really hard, given that they’re funded by the


Commonwealth, we’re funded by the State, for everyone to really show their cards and, sort of, reach an agreement on KPIs and etcetera, so that’s – I just throw that out there because I think that’s a space that I didn’t hear a lot today about, and maybe no so much – and when the ..... government sector, I guess, as Jo said before, there’s a mixed group of funding in that space. It’s just as complicated. Some LHDs fund 5 NGOs; the Ministry fund NGOs; the Commonwealth funds the NGOs. So there’s actually an interesting space that I think we need more work around. So that’s all. MS WALLACE: Thanks, Stewart. 10 THE COMMISSIONER: Unfortunately Martin, I guess, wasn’t able to join us today, so - - - MS WALLACE: Yes, yes. 15 THE COMMISSIONER: But can I just assure you, Stewart, that Indigenous health has been an enormous focus of the inquiry but - - - MR DOWRICK: I’m sure it has. Sorry. I’m sure it has, but - - - 20 THE COMMISSIONER: But I’m really glad you raised that in this context. MS WALLACE: Cathryn? MS COX: I think it’s hard to have a really good planning and funding discussion if 25 the Commonwealth is not at the table. MS WALLACE: Yes. MS COX: Because if we’re talking about a good continuum of care, primary care, 30 care in the community, then they have to be part of that discussion around, you know, how can you have different funding mechanisms, how can you plan so it’s coordinated and collaborative. I just think it’s – you’re really try to plan in a very constrained environment. 35 MS WALLACE: Yes. Thank you. Gerard. MR BYRNE: So, predominantly funded by Health, which is where it should be, but the services we provide are becoming less and less health-focused, as the range of complexities and the multiple issues that people bring have to be dealt with in terms 40 of, you know, their treatment episode – I’m thinking from the residential context at the moment, you know, where we’re looking at – of course, you know, there’s health – things around mental health and physical health and, you know, dental health outcome, as well as reduced or cessation of alcohol and drug use, but we’re also looking at, you know, having to reduce crime, get people into housing, get people 45 into employment, and also develop a family-inclusive practice framework – all on the same existing money.


And it’s not about the money, but it’s always about the money, and the reason for that is, without the resourcing, you can’t do it, and you can’t expand what you do and diversify your service base to meet the increasing need. There’s a lot of NGOs who sit on the historical funding. The historical funding needs to be enhanced, if they’re going to keep diversifying their service base to meet the broadening need of the 5 people who come through the front door. The new money comes with new things to do, and that’s fine. That’s how it should be. I’m a ratepayer at the end of the day; it’s good to see the – you know – the little bit I contribute to the state’s economy is used in the best way it can be. But by the 10 same token, the historical grants, the money that NGOs have been sitting on for decades – that needs to shift. It doesn’t need to get – as Larry made the point earlier on – it doesn’t need to go out to the market. If an NGO, ours or any other, isn’t getting to the market in relation to that funding, then that should be dealt with. And there’s mechanisms to deal with that. But that historical money does need to be 15 enhanced, and it needs to be enhanced outside of a competitive funding environment. And also, just to add in too, our service down in Canberra – we got a 40-bed residential service down there – around 45 per cent of people who’ve accessed that service are New South Wales residents, and we do trans-border service delivery for 20 them, and they don’t even hit the stats up here in New South Wales. MS WALLACE: Cross-border stuff is ..... absolutely. MR BYRNE: Yes. 25 MS WALLACE: Thank you. Theresa. DR ANDERSON: So I think the whole issue of workforce capability and development – whether it’s NGOs, primary health networks or districts – I think 30 there are lots of challenges in working in the space and making sure that we continue to support the development, and, I think, across all of our agencies, so not just within the NGO sector, or just within the PHN sector, or districts; actually coming together to do that workforce development and capability, and looking at what is best practice, and how we do that. 35 I think the issue of stigmatisation of both our clients and patients but very importantly the staff – and, you know, you can see that in things like the People Matter, and we’ve done a huge amount of work on that space to get a big shift in how our drug and alcohol staff see themselves, and the work – the amazing work that they 40 do – but also the impact of challenging behaviours on the workforce. And we do see that in our drug and alcohol services, in NGOs, but also in our emergency departments and cardiology departments, and other departments – in mothers’ and babies’ services – you know, how we collectively deal with those challenges. Because, I have to say, it is really tough, sometimes. 45


And, you know, I agree, we don’t want to have – absolutely don’t want our patients to be stigmatised. But it’s really hard with the staff, who are having to deal with some of those challenging behaviours. And how do we support them, mentor them, to be able to deal with that? And also, how do we debrief them in a way that doesn’t then affect the way in which they then see our next patients who come? 5 So – and also the issue of knowing what’s available. I thought lots of people knew that we did lots of work on homelessness, and it was only when we started running programs in homelessness, about three or four years ago, that we realised that half of our staff don’t know what we do in that space. And I think it’s the same in terms of 10 drug and alcohol and all of the services that fit around our patients. So being able to effectively communicate the full range of services that are available, and how we make sure that people can access them. Thank you. MS WALLACE: Just skip the next two; I’ll come back to them. Elizabeth. 15 MS WOOD: Look, I probably just want to echo Cathryn’s comments around the Commonwealth aspect, because that is a fundamental challenge for us. I think service provision across the continuum is something that we’re all very committed to, and we’d like to see better coordination. As I said, I think there are some 20 fantastic services that – and, as Theresa has just said, that we’re not even clear on – that are being provided and that exist. And certainly from a state perspective, we need to partner with the NGOs. You guys are critical; we can’t provide it all on our own. Nor do we want to. 25 Activity-based funding is absolutely a complex beast. Our patients are complex; our services are complex. But it does provide a level of transparency we have not had previously, and it does give us a mechanism to direct funds in a particular direction, to deliver a particular outcome. Where we are moving to, and what we do have available to us, is ABF state-only block, Commonwealth shared funding. And for us 30 it’s about districts and NGOs identifying what the model of care is, or the outcome that they want to deliver, and then us responding with a purchasing model that can actually fit that, as opposed to the purchasing model driving what the model of care or the outcome - - - 35 THE COMMISSIONER: Yes. MS WOOD: - - - should be. And I think, moving forward, as we’ve started on the Leading Better Value Care program, that’s a big piece of work we are doing. And also, just to reiterate again, the service agreement document itself is one part of that 40 overarching performance framework. It’s a very important part of it, but it is not the only part. And that document could never capture everything that we deliver in our system every day. And so that mechanism that is in place is critical for us. MS WALLACE: Alison. 45


PROF RITTER: Thank you. I’d like to highlight the dual system of care between government and non-government. I had a look at some of the figures. And this just reflects the specialist alcohol and other drug treatment, but government services, LHDs, provide 60 per cent of the episodes of care, and non-government services provide 40 per cent of the episodes of care, in any one year. And the increase of the 5 non-government services is increasing over time, if you look at the trend in the – in the data. And I would argue for a principle of equivalence in relation to things like contestability, unit pricing, length of contracts, key performance indicators. I think a 10 principle of equivalence between all of our service providers, whether they’re a government LHD or a non-government – or a non-alcohol-and-drug provider, like a homelessness service, who’s also providing treatment – I think a principle of equivalence would be a good aspiration. That’s the first point. 15 The second point is two things that haven’t been talked about today. The first is that there are a whole lot of other funding sources, other than government, whether that’s federal or state. Philanthropy plays an important role here, and I think Gerard has commented about the contribution that the Salvation Army makes to services. There are also client fees, which is an issue that is potentially fraught, and important in 20 considering the way in which services are funded. There are also Attorneys-General, Corrections, a whole bunch of other areas of government that fund alcohol and other drug treatment, that we need to keep in the frame of understanding, planning and funding. 25 And the last thing that hasn’t been raised is what I perceive to be a highly problematic word, and that’s the word “duplication”. It appears in a number of places throughout the paper, and it’s often said to me we have a problem with duplication. And my answer is, what is the problem with duplication, and what is being duplicated? And I think there’s a lack of clarity about this concern about 30 duplication. It’s a concern of the Commonwealth, I might add. Are we talking about the duplication of services? Well, we can’t be, because there isn’t enough services. So the problem is not that we’re duplicating beds or counselling services. So if that’s what we say be – mean by “duplication”, that’s a 35 kind of a nonsense. If we’re talking about duplication of planning, that’s a real problem. We’ve got multiple units doing planning, and we should stop duplicating planning. It’s expensive; it’s time-consuming; it consumes resource – important resources, like Mary said you had to participate in. If we’re talking about duplication of commissioning, that is also a problem. Multiple contracts, multiple arrangements 40 – so that’s problematic duplication. The last bit of duplication is the hardest, and that is duplication of funding. This is sometimes referred to as “double-dipping”. When a – I know, but we’ve got to talk about this. 45 MR PIERCE: Yes.


PROF RITTER: When a service receives a grant from the Commonwealth to provide residential rehabilitation, and a grant – sorry to pick on resi rehab; I’ll do - - - MR PIERCE: No, no, no, no. 5 PROF RITTER: - - - inpatient withdrawal. MR PIERCE: No, no. 10 PROF RITTER: A grant from the state government, and there has been, I think, terribly awful language used to describe this as “double dipping”, as “inappropriate use of funds”, as “duplication of funding”. Clearly I don’t agree that it’s duplication of funding. What I think the problem is, is the ability to account back to the funder for those funds, so some services who are funded for 10 beds do report those 10 beds 15 to funder A and the same 10 beds to funder B, but the problem is funding is fungible and they need both of those sources of funding to deliver the outcomes associated with the 10 beds, so I would argue, again, that the duplication of funding is – needs to be unpacked in a sensible and careful discussion about accountability for funding to multiple funding sources. 20 MS WALLACE: Thank you. Larry. MR PIERCE: Hoorah Alison. Thank you. I was going to make a couple of those points myself, but you’ve said it very well, and with no vested interests like I have. 25 So about ..... vested interest. We just like to support Gerard’s comments, and all my colleagues’ comments. They’re all – they’re all so valid for consideration by the Commission. With respect to putting it on the table, though, I think what’s absolutely clear – and, Dan, you have said that it is abundantly clear that there are just not enough places and room in treatment services to meet the demand. Not the 30 DASPM projected demand, but that real, human demand. The one in three or four people we’re actually turning away every day. So we have submitted a number of things to the government about the need to very quickly review and enhance the NGO treatment funding program administered from New South Wales Health. 35 It’s 57 million out of the 235, so that’s about 25 per cent, but, as Alison said, we see about 40 per cent of NMDS. We’re accountable for about 40 per cent of the NMDS, barring opioid treatment, yet we’re only funded at 25 per cent of the alcohol and drug budget, so we have, currently, a submission with government to enhance residential rehab beds, and I’ll let that sit there, but we would also argue that it is entirely 40 appropriate to make a 25 per cent, immediate 25 per cent, increase to NGO service budgets to assist them with meeting and maintaining the capacity that the additional compliance burden that Gerard and others have talked about, and also maintain some wages parity and some stability in their workforce, and that 25 per cent works out at about 14.25 mil. It’s not a big ask out of a state treasury, and it would go a long way 45 to stabilising the capacity and health of that current NGO sector providing 40 per cent of the NMDS, so – but they’re my final points.


MS WALLACE: Thank you ..... Michael. DR MOORE: Okay, so I’ve got two things: (1) and this might be out of scope, but let’s call for Australia to be a well-organised federation, you know. The time has passed, you know, that we all sit around and go, “Oh, you know, there’s this 5 Commonwealth and state funding, and, oh, it’s such a mess.” Let’s sort it out. Like, let’s put it on the table, it’s a problem. Let’s actually call it out and let’s get on with it and fix it. That’s point number (1). Point number (2), and this is from my own perspective, let’s have some best practice program funding logistics, so by that I mean, let’s have three-, or, as someone mentioned, four-year rolling contracts. 10 Let’s look at regionally pooled funding to get away from this duplication of funding, “duplication” in inverted commas. Let’s have fewer tenders and more necessary tenders, and let’s have fewer, larger, longer contracts with fewer KPIs, with consistent KPIs and consistent reporting software, just to – like, all the business 15 overhead stuff should be made as efficient as possible so that, you know, out of every dollar that goes to an organisation, as much as possible is spent on providing services. Let’s not be unnecessarily wasting money on overhead when we don’t have to. Having said that, let’s make sure these contracts are managed properly and that there’s proper KPI systems in place, and so that people are accountable. 20 MS WALLACE: And that there’s feedback back from it as well. DR MOORE: Yes, absolutely. They’re properly managed. 25 MS WALLACE: Yes. THE COMMISSIONER: Michael, consistent reporting software. Is that a reality? Is it there at the moment, or should that be developed? Is it - - - 30 DR MOORE: I don’t know. Look, okay, you may not necessarily have consistent reporting software, but you might have reporting standards so that people can use whatever software they want ..... but there will be a – there will be a data definition so that, you know, you have a CSV file format that’s – and it doesn’t matter what software you use, you can always transfer your - - - 35 THE COMMISSIONER: Yes. DR MOORE: - - - stuff, so, I mean, most people have, you know, customer relation management systems that they can extract data from and make it easy for them. 40 THE COMMISSIONER: Yes. MS WALLACE: Jo? 45 DR MITCHELL: Well, look, I think the ICT development is a huge area. We haven’t really talked about it at all, and it’s certainly something that, you know,


we’re interested in this part of that data capability side of things. Look, I think just the comment that I’d make is that, just by the nature of the discussion, we’ve been talking about planning and funding, but it’s also sort of always looping back to making sure that the implementation and the delivery is actually making the difference that we want it to do, and that’s really, really fundamental, so I think that’s 5 just a comment. The main sort of issues for me sort of come to that – that we are building our capability around data and evaluation and outcomes as a system, and that we should continue to do that, but that becomes really important for us, and I’m also struck by a 10 number of the comments from people around the room as well, around the focus on consumers and patients and the move to PREMs and PROMs as part of that process, the move to engaging with people and their families about, you know, what works, but also in addressing the issue of stigma and discrimination. 15 So I think it’s fair to say that there’s sort of a number of steps that we’re taking in New South Wales around those issues, which we continue to need to do that, and I know that sort of one of our visions is, in fact, for a joined-up system, and so these kinds of conversations are really important around that sort of connection between the different inputs, but it is complex. It’s more than beds, and we do hear a lot 20 about beds, but it’s more than beds, and it’s more than, you know, one mode of delivery, and it’s more than one drug type as well, so I think it’s just really important that we reflect back on that as we go forward with this too. MS WALLACE: Thank you, Jo. Amanda? 25 MS LARKIN: So I’ve got a little list. I have a couple of things. MS WALLACE: A little list or a big list? 30 MS LARKIN: I have got a little list, yes. I just want to cover the concept of NGOs, and I think, if I was on the phone at our last NGO meeting, I’m going to repeat myself, so bear with me. For those who have lived in the system very long, NGOs were created around the 1970s. It was a way to deliver services in a much more flexible, less bureaucratic, if we can say it. NGOs could attract money from a range 35 of difference sources, were more flexible around recruitment, you know, retention of staff, good, bad or indifferent. I’m just thinking that the discussion we’ve had today is we actually have to, I think, as a system, recognise the true value of NGOs in delivering drug and alcohol services. They are very important players in how we do it. 40 I’m not quite sure whether our thinking has moved from the 1970s about them as agencies and how they function. I think it’s remained there, and, unless that changes, funding and the issues we’re asking them to do, like, things like – NGOs were never built to have all of these reporting systems and all about that, but now we’re asking 45 them to, because that’s where we are today, and I accept that, but our whole thinking actually hasn’t changed, and I think there needs – and we attempted to do it with the


ministry. It’s a very hard discussion, because we don’t only do it with drug and alcohol, we do it with others, but it’s a challenging environment, but unless we change our thinking and accept – and understand and accept the role that NGOs have, then I don’t think any of that tinkering around the edges, which is whether it be ICT or the funding arrangements, is really going to change, so that’s my first 5 thought. My second thought is that, Commissioner, you raised about the issue of whether we should put some money into, you know, increasing awareness about drug health. I absolutely agree that I don’t think that will affect. The advocacy and thinking and 10 change around mental health occurred when carers and consumers were empowered to actually drive the agenda strongly themselves, and you saw the system fundamentally change. That’s where you actually need to embed resources that support consumers to be valued in the system for their input and their – you know, their comment about how they’re treated in the system, all about that. Unless the 15 carers and the consumers are supported to do that, they’re the ones who will change the community’s perception around drug and alcohol, they’re the ones who will change the system in the long-term and get the recognition with drug and alcohol I think clients need to have in the system. Sorry, two more? 20 My next one is around the jurisdiction – the multi-jurisdictional. I honestly believe that health’s capacity to change a whole lot of the care and delivery of care for drug and alcohol clients is really limited because the jurisdiction – there isn’t multi-jurisdictional management of the service. Unless that changes and we have some way – and I know there are systems and processes at the moment, but it really needs 25 to change. If you look at what Theresa was talking about, a large issue for drug and alcohol patients is – and mental health at times – but drug and alcohol, is housing. They don’t have a place to live for lots of different reasons – because they can’t pay the bills and all of those things. Unless we actually deal with it multi-jurisdictionally, it’s not going to change, because we will only ever change a 30 component of the business. And my last one, though, is when we’re thinking about funding, I know we’ve talked a lot about the services that are in the NGO environment, but there are a lot of services in the acute – so I’m just reinforcing three areas, which is community, acute and NGO, and unless we deal with that altogether, again, the system won’t shift. 35 MS WALLACE: Thanks, Amanda. Walter. MR KMET: I think a lot of work has been done on defining a lot of the ingredients to have better outcomes in this area. I guess the next challenge, I think, is the 40 implementation challenge. How does that look like one model of care across a system that combines NGOs, government, different levels of government, into one view as to what this continuum of care should look like. And as ..... said, we should fund that. We should look at funding that, because that’s the right thing to fund. 45 You know, we’ve almost perpetuated, I think, the fragmentation, small funding around the NGOs and other areas –and I agree with your comments, Amanda – partly


because we don’t have a view as to what the system should look like as a whole, so we keep funding what’s there, and there’s sort of this piecemeal approach and this ..... piecemeal approach that over time becomes quite unworkable. So as I think Amanda said, you end up having a system that’s not fit for purpose anymore. I think we should focus on that implementation challenge and a definition. 5 I think we should focus on being able to ensure that from a funding point of view, we’re absolutely transparent about where we want to go with funding, and we’re saying here, okay, a good system, whatever that system might look like – better experts in the room than me – would have this amount of money going to that part of 10 the system, this amount of money going to that part of the system, this amount of money going to that part of the system, and over a period of time, 10, 15 years, there should be targets, system targets around achieving that, partly to deal with the reform thing I talked about earlier, partly to do with raising the water level. 15 And the last thing I wanted to say is I think – and we haven’t talked about this too much today, but there is – I mean, we have talked about comorbidities a lot in terms of social determinants and so on, but remember Larry, we had a lot of discussions about the mental health/AOD nexus, and there are pluses and minuses about that, and I accept those, but there are real issues around integrated care, whole person care, in 20 terms of that – those funding pools that I think need to be looked at, because maybe – if there is one area of duplication that does take place, inverted commas, it’s probably there. You know, because we are looking at not being able to define what is – you know, what is a good outcome in any one of those two areas. 25 MS WALLACE: Glen. MS JAMES: I would like to just reinforce that there is a need for investment in workforce development in the AOD sector, and not just in the NGO but in the health sector as well, and around planning, and including peer workforce, because we know 30 – you know – we know how effective a peer workforce can be. And the need for investment and integration, again – just like Walter said – around mental health and AOD: you can’t – you can’t just draw the line around that. And especially around co-occurring conditions. 35 So I think there is a urgent need to review our funding and planning models that we actually have in New South Wales, you know, across Commonwealth, PHN, LHD and Health. And I’m really curious, and really keen, that we’re involved in a shared investment model, around joint planning and priority setting, so we can have shared resourcing, and a commitment to pursue the best return on investment for on-ground 40 AOD outcomes. And lastly, I know this inquiry is specifically around ice, but we really need to consider the link with earlier alcohol and other drug trajectories that lead to the use of ice. THE COMMISSIONER: Yes. 45 MS JAMES: Thank you.


MS WALLACE: Good. THE COMMISSIONER: Thank you. MS WALLACE: Thank you, everybody. I’m going to hand over to the 5 Commissioner now, to - - - THE COMMISSIONER: Well, look at that timing, Leanne. That’s just perfect. MS WALLACE: Unless Nick has got any other questions you wanted to ask, or - - - 10 MR KELLY: No, I – maybe one observation, and - - - MS WALLACE: Yes. 15 MR KELLY: - - - something that we haven’t really talked about, is that there’s been a lot of discussion around data, and data being one of the fundamental building blocks of both planning and funding. And I’m troubled by that in the context of having had, now, hearings around this day, where every single service provider has said that “The data that we presently collect significantly underrepresents the scale of 20 the problem.” So that – the extent to which data is an answer here is really good to hear, but it’s troubling to me, at the same time, that the evidence that the Commission has heard doesn’t necessarily square with that. THE COMMISSIONER: Thank you, Nick. Well, look, I just want to thank 25 everyone for their contribution today. I think this has been a really helpful private hearing that we’ve had today. We’ve gone down a lot of avenues that are very important ones for this inquiry. I’m taking a lot of messages away from what’s been said today. I’m going to look at that transcript very carefully, as any of you may if you – when you get it. And I think there’s a lot that will lead to, certainly, inform 30 my recommendations in this inquiry. I’m really grateful to all of you for spending so much time with us today. And thank you very much for coming. And thank you to Leanne for facilitating this so thoroughly well. 35 MATTER ADJOURNED at 4.02 pm INDEFINITELY Participants: 40 DR M. MOORE – CEO, Central and Eastern Sydney PHN MR W. KMET – CEO, Macquarie University Hospital and Clinical Services (formerly, Western Sydney PHN) 45 MS G. JAMES – Executive Director for Mental Health and AOD, North Coast PHN


PROF A. RITTER – Social Policy Research Centre UNSW DR M. HARROD – CEO, NSW Users and AIDS Association (NUAA) DR J. MITCHELL – Executive Director, Centre for Population Health, NSW Health 5 MS E. WOOD – Executive Director of System Purchasing, NSW Health MS C. COX – Executive Director, Health System Planning and Investment Branch, NSW Ministry of Health 10 DR T. ANDERSON AM – Chief Executive, Sydney LHD MS A. LARKIN – Chief Executive, South Western Sydney LHD 15 MR S. DOWRICK – Chief Executive, Mid-North Coast LHD MR L. PIERCE – CEO, Network of Alcohol and other Drugs Agencies (NADA) MS C. HEWETT – CEO, Kamira 20 MR G. BYRNE – State Manager, AOD Services (NSW/ACT & QLD) – The Salvation Army MR N. HENDERSON – Senior Drug and Alcohol Worker, Weigelli Centre 25 Aboriginal Corporation

transcript of proceedings · 2019-10-02 · transcript of proceedings o/n h-1058521 mr d. howard...

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