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MEMBERS:
Hon. S.G. Wade MLC (Chairperson)
Hon. J.A. Darley MLC
Hon. T.A. Franks MLC
Hon. T.T. Ngo MLC
WITNESSES:
JELBART, MIRANDA, Medical Director, South Australia Brain Injury Rehabilitation Services
SMITH, BRIAN, Director of Respiratory Medicine, The Queen Elizabeth Hospital
BONNIN, ALASTAIR, Director of Medical Services, Central Adelaide Palliative Care Service
WINSOR, ADRIAN, Head of Rehabilitation Medicine, The Queen Elizabeth Hospital
VISVANATHAN, RENUKA, Director of Geriatric Medicine, The Queen Elizabeth Hospital
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The CHAIRPERSON: It being 10.30, I propose to convene the meeting of the Select
Committee on Transforming Health. I will introduce Sue Markotic, our research officer; Tung Ngo, a
member of the committee; I am Stephen Wade, a member of the committee; Mr Guy Dickson, who
is our committee secretary; and Hansard is also with us. We are having a public hearing here and
then a private visit to The Queen Elizabeth Hospital after the meeting.
I welcome everyone to the meeting. The Legislative Council has given the authority
for this committee to hold public meetings. A transcript of your evidence today will be forwarded to
you for your examination for any clerical corrections. Should you wish at any time to provide
confidential evidence to the committee, please indicate and the committee will consider your request.
Parliamentary privilege is accorded to all evidence presented to a select committee. However,
witnesses should be aware that privilege does not extend to statements made outside of this meeting.
All persons, including members of the media, are reminded that the same rules apply as in the
reporting of parliament.
I understand there is at least one witness who would like to make an opening
statement, so what I propose to do is ask each witness who would like to make a statement to make
a statement and then we will go to questions. I invite Dr Jelbart to start. If you wouldn't mind
introducing yourself, which unit you are from and what role you have in that unit.
Dr JELBART: My name is Dr Miranda Jelbart and I am a rehabilitation physician
within central Adelaide. I am the Medical Director of the South Australia Brian Injury Rehabilitation
Services, which is based at the Hampstead Rehabilitation Centre. I have worked in South Australian
rehabilitation for over 30 years. My service is the sole brain injury specialist rehabilitation service in
the state, and there is no other private service fulfilling this role. My service has a statewide role and
catchment area, accepting patients from every region, including rural and remote, Northern Territory
and far western Victoria.
Thank you all for engaging with us to inquire into the impact that the state
government's Transforming Health initiative will have upon rehabilitation services, particularly in the
Central Adelaide Local Health Network. I am the first of the unit heads representing Hampstead
Rehabilitation Centre and The Queen Elizabeth Hospital reporting to you today. We will each
introduce ourselves and our specialty, and will then address our concerns about the Transforming
Health rehabilitation strategy and its impact on each service.
As you will hear, the Transforming Health rehabilitation strategy in central Adelaide
involves the reduction of Hampstead Rehabilitation Centre beds and major displacement of many
existing services at The Queen Elizabeth Hospital site, and this is why so many of us are here today.
In health service terms, rehabilitation forms part of the constellation of subacute services, and these
include palliative care, geriatric evaluation and management, and psychogeriatric services. These
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three are on The Queen Elizabeth Hospital site currently and have been for a number of years, as
you will hear. There are three rehabilitation services that will be moved from Hampstead: statewide
brain injury rehabilitation, spinal cord injury rehabilitation (also a statewide service) and central
Adelaide general rehabilitation.
We believe that your inquiry needs to go beyond central Adelaide rehabilitation
services. We predict that the Transforming Health strategy and its timing for moving all rehabilitation
beds from Hampstead to this site will inevitably damage other TQEH services, both acute and
subacute. The new Royal Adelaide Hospital will then bear the brunt of the downgraded The Queen
Elizabeth Hospital site and services.
Moving Hampstead to QEH makes sense. Synergies due to patient co-location, such
as reduced ambulance travel between sites, shared investigation services and better after-hours
cover, can and will occur and will bring about significant cost savings. Hampstead clinicians are
enthusiastic to move patients to this site, which is an effective, well-recognised tertiary acute hospital.
We all recognise our patient will benefit. This is contrasted with the standalone Hampstead site:
x
x
x
x
no overnight, on-site medical staff; they are on remote call;
no on-site radiologist;
X-ray only two afternoons a week, and that's plain X-ray only, no scans; and
ambulance travel to and from everywhere else for almost any specialist review.
Yet, currently, Hampstead manages to provide excellent rehabilitation within these constraints. The
Queen Elizabeth Hospital clinical staff also want on-site rehabilitation for their patients, faster
assessment, faster starting of rehabilitation and more efficient use of all resources—all the benefits
of co-location.
We clinicians agree that changes are needed to transform rehabilitation in
Central Adelaide and statewide. We do uphold the aims and vision of Transforming Health, and we
are onboard; however, we strongly assert that this should not be at the expense of existing programs
and pathways that are working very well and provide excellent quality.
Statistical modelling and decision making for Central Adelaide throughout 2015 and
earlier was conducted by Transforming Health and largely focused on the new Royal Adelaide
Hospital but, inexplicably, Queen Elizabeth clinicians were kept out of that loop. Decisions were taken
without any consultation re the impact on clinical pathways at this site—The Queen Elizabeth—with
limited or no reference to QEH clinical lead services and persons.
We just found out on Wednesday this week that statistical records to which all
rehabilitation services throughout Australia report nationally, known as the AROC (Australian
Rehabilitation Outcomes Centre) appear to have been misconstrued by Transforming Health to
further disadvantage Central Adelaide rehabilitation.
Our combined group has been meeting collegially and grappling with these matters
since early January. We predict far-reaching ramifications if the current Transforming Health strategy
to move rehabilitation by displacement is implemented. Dr Winsor will also speak further about the
use of statistics.
We fear that there will be a domino effect of negative impacts for the Hampstead
cohorts and, in turn, severe disruption of QEH subacute specialties when displaced. We predict a
chain of events that will damage quality and effectiveness of rehabilitation and of many QEH services,
irreversibly. Each site will actually end up worse off rather than having mutually enhanced patient
pathways and beneficial tertiary hospital services. Staff will also be significantly disadvantaged.
These possible consequences of the Transforming Health displacement model
should have been but never were explored with the senior QEH clinical staff. Furthermore, a number
of these senior staff who tried to engage with Transforming Health were actively excluded over
months from meetings and requested meetings.
Although Transforming Health reported to parliament in September last year that the
majority of senior clinicians at Queen Elizabeth Hospital had agreed to the plan after extensive
consultation, we can assure you that this was untrue. Our concerns have only been formally
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acknowledged since early December last year, 2015, after we sought union involvement by SASMOA
(the South Australian Salaried Medical Officers Association).
The new Chief Executive Officer of Central Adelaide, Ms Julia Squire, has agreed to
meet with all the clinical leads from both sites, and we're pleased to acknowledge her ongoing
engagement with us starting in December at structured weekly meetings to probe more deeply into
our concerns with the aim of finding a solution in collaboration with the clinicians. This is to ensure
that our patients and the community continue to have the best possible standards of health care.
We have very specific concerns about how Transforming Health is implementing and
timing its strategy. The budget allocation of around $22 million to support the Hampstead move and
the new infrastructure required, and to enable integration of all services at The Queen Elizabeth
Hospital is staggeringly inadequate. We believe that a new build should be seriously considered and
commissioned.
In closing, I will briefly mention the Brain Injury Rehabilitation Service to define some
of the key issues in moving it to The Queen Elizabeth site. We accept a very broad spectrum of case
mix; they are predominately younger adults of working age with severe to very severe acquired brain
injury. This broad spectrum and case mix poses many challenges in care for the entire
multidisciplinary team that is required to manage and rehabilitate them.
Our patients need a secure ward with a lockdown facility. They need quiet areas
where agitated patients can be calmed and secluded. We need therapy spaces within the ward to
reduce noise and to reduce the agitation factor. We also need secure ground level accommodation
to access outdoor spaces for safety and seclusion from the busyness of the world which will
aggravate our patients' disinhibition and problems.
We also need spaces for outdoor mobility training because these are young, fit and
often active patients, although we also have a slightly older case mix on occasion. The statewide
rehabilitation services, brain injury and spinal cord were called to a series of time-limited, architect
planning meetings each fortnight from August through to September last year, with a deadline of
October 2015. We were tasked with designing our structural facilities at The QEH according to our
specifications and requirements but, to our dismay, we were told that our move was predetermined
into buildings already occupied by fully functioning specialist services of geriatrics, respiratory and
palliative care.
Furthermore, our staff were specifically prevented by Transforming Health from
visiting the proposed site to better understand the space and the constraints we faced in design, but
were told that the current ward occupants have not yet been informed that they would be—may I
say—evicted in favour of our clinical services. We were also specifically instructed not to discuss this
matter with any QEH clinical staff.
Despite our best efforts, the final space, design and availability of these
predetermined sites did not accommodate our staff or our patient needs and were inadequate for
brain injury rehabilitation at best practice. We would face a downgraded service and facilities if the
plan goes ahead. The South Australian Brain Injury Rehabilitation Service cannot agree to the
destruction of the existing geriatric evaluation and management unit.
This would spend scarce state health funds to alter it substantially to be fit for our
purpose. It would, in effect, be shoehorning our brain injury service into The Queen Elizabeth Hospital
GEM unit which is a purpose-built centre of excellence, as you will hear from my colleague. It will be
unsuitable for our brain injury patient rehabilitation, even if extensively and expensively remodelled.
Thank you.
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The CHAIRPERSON:
Professor Smith?
Thank you, Dr Jelbart. Who would like to speak next?
Prof. SMITH: My name is Brian Smith. I'm the Director of Respiratory Medicine at
The Queen Elizabeth Hospital. The respiratory ward is a purpose-built ward. It was laid out when
that section of the redevelopment occurred to specifically and in a very carefully designed way meet
the needs of patients with severe respiratory illnesses.
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As a result of the good design and excellent staff retention and skills, we've got a
shorter length of stay than, for example, the Royal Adelaide Hospital for pneumonia and a very
common condition COPD, or emphysema. It's one to five days shorter than, for example, the Royal
Adelaide Hospital for the same conditions, despite our patients being considerably older; so, clinically
it's good performance.
In terms of our laboratory, we are the first hospital in Australia to have accreditation
of all respiratory laboratories and at the most recent reaccreditation have been described as having
the leading benchmark for quality. In terms of research, which is another perspective on what we do,
we have been awarded $1 million from highly competitive peer-reviewed NH&MRC grants. We
employ about 10 youngish South Australians through our research programs; so, clinical, laboratory,
research and teaching. As of last week, probably arguably the most prestigious award recognition of
your postgraduate teaching is the Young Investigator Award for the Thoracic Society, which we won.
On the usual parameters of good clinical practice, we're performing quite well, so
you can imagine it makes you feel a bit low to pick up the Messenger press in your driveway to find
that, despite claims of extensive consultation with you, that none of us actually received, your ward
and your high dependency bays are now a dining room for Hampstead patients being transferred.
It's disappointing because we actually had heard this might be happening and had attempted to talk
to the CEO at the time and various other administrators, who basically declined to discuss it. So the
22 September report, which claimed extensive consultation with TQEH clinicians—none of us having
that consultation—was, frankly, untrue.
On a positive note, we are pleased with the discussions, really initiated through
Bernadette Mulholland and SASMOA through the IRC. The discussions are happening on a weekly
basis with our more recently appointed CEO. So, for respiratory medicine, had they asked us a year
or so ago we would have said there is one solution and it's the clear solution, and that's to incorporate
this acute high level, high complexity ward into the new hospital. After all, there's all this talk of best
care first time, right place, and single service, so for the respiratory acute service it's always been
our view that an integration into the new hospital would make the most sense.
The plan that was put to us belatedly at the end of last year was basically to squeeze
our service into the back end of another ward that wasn't purpose-built here at The Queen Elizabeth,
going from our three TB, SARS contagious rooms down to one, with no discussion at all, losing our
high dependency bays, losing our observations areas that Jenny Richter and I and some others
purpose designed about a decade ago.
So, we've got a problem with communication and, I guess you could say, a bit of
good old-fashioned respect, really, and perhaps some acknowledgement that some of us know what
we're doing and how we've designed our wards and how we perform. We are optimistic that our new
CEO is going to continue to make progress in that area. We are really looking for some rational
planning. Some of us are quite keen to identify how we got into the current situation so it doesn't
happen again, because frankly if our current CEO was to leave—and they all leave, with a turnover
of about 12 months—we'll be back exactly where we were. We feel somewhat concerned that it's
really sitting on a knife's edge in terms of where we go from here.
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The CHAIRPERSON: Thank you, Professor Smith. Shall I just go through the list?
The next one I have on the list is Dr Bonnin.
Dr BONNIN: My name is Alastair Bonnin. I am Director of Medical Services at
Central Adelaide Palliative Care. I have worked at The Queen Elizabeth Hospital since I was an
intern in 1986 and in palliative medicine since 1989. Central Adelaide Palliative Care provides a
comprehensive multidisciplinary care network across the Central Adelaide Local Health Network
region. There are inpatient units on three sites: the Royal Adelaide, the Mary Potter Hospice at
Calvary North Adelaide, and The Queen Elizabeth Hospital.
Consultation liaison teams provide advice and support to other specialty units at both
of the major hospitals. There are community teams based here at The Queen Elizabeth Hospital
providing home care and support across the region, and there is a comprehensive bereavement
support service based here at The Queen Elizabeth Hospital as well. With regard to the current
inpatient unit on North Ground B, Queen Liz, the Palliative Care Services Plan 2009-2016 states:
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The development of a hospice unit at The Queen Elizabeth Hospital is a priority. This unit will be
part of the Level 6 palliative care service based at QEH and will need to have the capacity to provide 24 palliative care
beds within the next 4 years. This hospice will serve as the main centre of inpatient palliative care in the western,
central and eastern suburbs of Adelaide.
The recently confirmed Department of Health medicine directorate commissioned bed statement
shows palliative care at The Queen Elizabeth Hospital with 12 beds through to June 2016, increasing
to 16 by December 2016. The current unit was, as with the respiratory unit, purpose designed and
built with detailed input from our multidisciplinary team.
The first draft plan located the unit on the first floor, but we were able to make a
convincing case that direct ground floor access to the sheltered garden area was a central design
element, allowing terminally ill patients the opportunity to be outside, if necessary in a bed, to enjoy
some connection with nature in their last days.
There are 12 beds currently, of which 10 are in single rooms. The rooms are
designed to be larger than standard to allow for families to be present through the 24-hour cycle, and
all have ensuite bathrooms. They have shelves for personal belongings and small fridges for food
and drinks. Most have direct access to the garden through large glass doors.
The area is open, and has a sense of light and space with wide corridors. There are
good lines of sight to many of the rooms, which is crucial for patient safety in a population with a very
high incidence of delirium and falls. The unit has a close architectural and functional relationship with
the geriatric evaluation and management unit in the next pod.
Those are the minimum elements of a comparable new ward. If relocation does
occur, or even if it does not, we would argue that those elements should be maintained.
There is broad support for many of the elements of Transforming Health. Many of
the reforms are common-sense and necessary reforms, and in particular the relocation of the
Hampstead Rehabilitation Centre to QEH is strongly supported. The problem is not with the
concept, but with the process. We were first given some intimation in July that we may be required
to move in order to make way for the incoming rehabilitation services. We were told that we might be
ending up in North East Ground A, but it was not until last month, after the engagement of SASMOA
and the Industrial Relations Commission, and months of weekly meetings with the CALHN CEO, that
we were shown a floor plan, which was of North East Ground A, unaltered and with a daub with blue
highlighter across it saying, 'This is where the palliative service goes'.
That included four-bed bays. Patients dying in four-bed bays with no privacy or
dignity was the practice that prevailed 20 years ago. I will acknowledge that there has been a recent
development. The manager for infrastructure of SA Health visited on Tuesday and showed us a
rough sketch of a floor plan for a new build on top of the existing new allied health building, which is
a very encouraging development and something that is very exciting.
However, I want to emphasise that we, like all other units, exist in an interdependent
and, if properly designed, synergistic relationship with other units, and so we will not be prepared to
engage in the process of moving to what is a very tantalising opportunity for a new build if that is at
the expense of the structure or downgrading of other units and the loss of our interdependent
relationships.
Dr WINSOR: Thank you. I am Dr Adrian Winsor. I am Head of Unit for Rehabilitation
Medicine at The Queen Elizabeth Hospital and I am the lead rehabilitation medicine consultant for
general rehabilitation at the Central Adelaide Rehabilitation Service. I am also a program director for
a private rehabilitation hospital, Griffith Rehabilitation Hospital, at Hove in Adelaide.
I support, in principle, the idea of the move of general rehabilitation from Hampstead
to this site. Our service currently has 75 inpatient beds at Hampstead Centre. Patients in our units
have had conditions such as stroke, post complex medical or complex surgical procedures, or post
orthopaedic procedures, such as fractured neck of femur, hip replacement, joint replacement,
amputation and post burns. We also have 20 rehabilitation in the home beds and an ambulatory day
rehabilitation service based at this site—The Queen Elizabeth Hospital.
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We triage patients from all over the state. Our principal triage is from the
Royal Adelaide Hospital and The Queen Elizabeth Hospital, but we also receive patients from other
sites and private acute hospitals.
My main concern with regard to the move is the number of rehabilitation inpatient
beds that have been allocated to the central Adelaide region. Prior to Transforming Health, all of the
reviews of rehabilitation services and subacute services in this state indicated a need to increase the
number of inpatient beds and ambulatory services across metropolitan Adelaide, including the central
region.
At our first meeting with Transforming Health in May last year, we were advised that
the number of inpatient rehabilitation beds in the central region would be reduced to 33. We were
told that that was based on AROC (Australasian Rehabilitation Outcomes Centre) data. I have
spoken to the manager of AROC and I know that no-one from South Australia Health has had an
interaction with AROC about how their data should be used.
AROC data should be used carefully. It requires an understanding of local conditions
and resources. AROC data should not be used, for example, for financial planning, and I would say
that it needs to be used very carefully in determining resource allocation and bed numbers.
We challenged SA Health and Transforming Health regarding that bed allocation and
mid last year they increased it to 43 on the basis of an unmet need. We again challenged that number
and this year we were advised that the reason for the allocation being reduced in the central region
was because patients in the central region had greater access to private rehabilitation hospital beds.
We were also advised that future planning was that country patients and patients
resident in a north-east corridor of postcodes currently in the central region would be sent to either
NALHN or SALHN (Northern Adelaide or Southern Adelaide) for their rehabilitation; however, their
acute management would remain in CALHN. This causes us concern because there will be a
disconnect between acute care and subacute care requiring more travel for acute reviews and
causing a loss in the continuity of care and possible poor outcomes for patients.
I'm also concerned about the implications if patients with private health cover are
directed to private hospitals rather than being able to access public rehabilitation facilities and
inpatient beds. We know that, as the private rehabilitation hospitals generally take patients with lower
needs and shorter lengths of stay, then more complex patients with rehabilitation needs universally
come to public rehabilitation units.
650
The CHAIRPERSON: Thanks, Dr Winsor. In terms of two groups and half an hour
of time each, we are pushing into the next group's time. If we could be as concise as possible, we
will hear from Professor Visvanathan.
Prof. VISVANATHAN: I am Professor Renuka Visvanathan and I have been the
director of geriatric medicine at The Queen Elizabeth Hospital since 2005. I am a current member of
the ageing well subcommittee to the Economic Development Board of South Australia. As a clinical
service committed to translational research and education, we have been successful in attracting
external research education and training funding totalling almost $14 million since 2005, and as a
service, we are internationally known for our translational research, especially in the field of nutritional
frailty.
I'm currently project lead for the National Health and Medical Research Council of
Australia Centre of Research Excellence on Frailty where, with collaborators from across Australia,
we will develop new models of care for older people. I have had the privilege to be involved in state
health reform activities since 2009 in my role as a steering committee member of the SA Health Older
People Clinical Network. I held the position of deputy chair of that clinical network between 2011 and
2014.
I'm going to start off by stating that South Australia is leading the nation in terms of
population ageing and this Western region especially is home to a large catchment of very old people.
The fastest growing demographic in South Australia is actually the demographic of 80 years and
older. This is a subset of population that has great needs for health care and they have specific needs
from issues such as frailty, dementia and delirium.
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The older persons' network was very productive and developed several models of
care for implementation including one for South Australia's geriatric evaluation and management
(GEM) unit. I will now quote directly from this model of care document because it is portfolioendorsed:
Inpatient GEM units have been proven to improve outcomes of older patients and reduce admission
to residential care. GEM units are accepted standard of care in geriatric medicine for an increasing number of older
patients admitted to hospital who are frail, have multiple mobility and have significant impairment of function.
The Queen Elizabeth Hospital GEM unit is acknowledged as one of the best in Australia not only for
the quality and innovation of its clinical and academic services but also for the world-class facilities.
I would like to table this article by Professor Ian Forbes.
651
The CHAIRPERSON: Thank you.
Prof. VISVANATHAN: The South Australian government had the foresight to invest
in fantastic infrastructure for its older citizens through its stage 1 and stage 2B infrastructure builds
at The Queen Elizabeth Hospital. The stage I building that provides for the state-of-the-art GEM unit
was designed by an internationally renowned architect, Professor Ian Forbes. Professor Ian Forbes
was awarded a lifetime achievement award in 2013 by the International Academy for Design and
Health, so he must know what he is doing. He published that paper on the stage 1 build, so I am
going to quote something from his paper:
…for the first time in Australia, a hospital has developed specially designed 'Healing Gardens'.
These are the gardens that surround our ward. He says:
…the 'backyard' garden off the geriatric ward [was] designed as a walking space and replicates
typical South Australian backyards with comfortable seating that provides familiarity for [patients with dementia].
Five single rooms and the GEM unit dayroom look out on and have access to this garden. The GEM
unit dayroom has been further enhanced through generous donations from our community, the West
Lakes Lions club.
Next, the patients in our secure and therapy areas have access and use to the
journey garden. The journey garden is designed to promote active movement and gait training when
walking in the garden. It offers different surfaces, rises, steps and seats for resting. Other rooms in
the GEM unit have use to the fragrant, sunken and atrium gardens. The windows allow for natural
light into the ward, which is very important for patient care. The internal layout of the ward provides
a feeling of safety and encourages mobility, so as clinicians we need all of this infrastructure to help
our patients recover sooner and regain independence.
When the state health plan was announced, it was determined at The Queen
Elizabeth Hospital would be home to centres of excellence in geriatrics, rehabilitation medicine and
palliative care. Then, the stage 2B investment occurred. This development linked the GEM unit to
the inpatient psychogeriatric medicine ward and ambulatory allied health and therapy services. It is
for the above reason that we were actually taken by surprise in August 2015 when we noted a
presentation by SA Health's director of infrastructure—and that too was only through a SASMOA
bulletin to doctors; so, it was not a presentation to us, but a presentation to the union.
We attempted to engage and consult with management in Transforming Health, but
there was no reciprocation, so we actually got the rest of the information from the Portside Messenger
and the Public Works Committee report. We were especially concerned about the information
presented on page 9 of the Public Works Committee report, where only $20.4 million was allocated
for the rehabilitation build. There appeared to be no discussions about the cost incurred from loss of
existing investment, as well as the necessary cost to be incurred through redevelopment for all the
displaced services.
We were finally only told by CALHN management on 18 November 2015, and it was
then that we were alerted to the domino consequences to other services in the hospital and for our
patients. We had additional concerns because we gathered that there might be two transitions
through 2016, including through winter, through wards that are not purpose-built for our patients. To
us, that would actually be detrimental to patient care, cause stress to staff and patients, and introduce
risk. So, as a whole, it did not make much fiscal sense to us to destroy good investment.
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Assoc. Prof. KIROFF: I am Associate Professor George Kiroff, a consultant surgeon
of more than 30 years' surgical experience. I will not go over the ground that my colleagues have
already covered very adequately. The concerns of the surgical community are twofold: firstly, this
plan, when implemented, will result in an overall loss of rehabilitation beds in the central area,
decreasing the ratio of rehab beds from 16:100,000 currently to about 9:100,000.
We applaud the whole notion of integrating rehabilitation with an acute hospital
facility (in this case, The Queen Elizabeth Hospital) and we welcome that for the reasons that have
already been stated. The benefits of synergies, of shared resources and of shared support are
obvious. What we cannot countenance is the negative impact of a relative lack of access to
rehabilitation beds for our acute surgical services.
There will be two impacts there: there are streamed surgical services such as
arthroplasty—my orthopaedic colleagues will elaborate on that a little later in the second session. If
a government is interested in getting bang for buck, you cannot get more bang for buck in the
expenditure of the healthcare dollar other than having a streamlined arthroplasty joint replacement
service. This is where you get the most quality-of-life impact, and if you can have that integrated with
a rehabilitation service onsite, that would get you a very good result.
As a general surgeon, we are concerned because access to rehabilitation beds, after
recovery from an acute surgical intervention, is the greatest single impact on our overall length of
stay. If we cannot get that patient assessed rapidly, if we cannot have them transferred rapidly into
a lower-level bed, that impacts very negatively on our length of stay. When we look at our length of
stay it is these patients that contribute to the overall length of stay being adversely impacted.
The second category of our concerns relates to possible loss by displacement of
acute services. We rely on colleagues such as Brian Smith and his team here in respiratory medicine
and cardiology, and particularly in palliative care. Any loss of palliative care and respiratory support
for acute surgical interventions would have a very negative impact on us in general surgery in The
Queen Elizabeth Hospital.
652
The CHAIRPERSON: The recurring theme across all your presentations is that
there is no fundamental objection to the Hampstead co-location with The QEH but that the
$20 million—or possibly $22 million was mentioned—would be inadequate to provide a similar level
service on the consolidated site. Does anyone have any idea of how much would be required to
provide a similar level of service on the consolidated QEH site? Does anyone have a feel for that?
Prof. VISVANATHAN: We do not have high quality—
Assoc. Prof. KIROFF: I think that would require detailed planning, and we have not
engaged in detailed planning for that.
653
The CHAIRPERSON: So it looks as though respiratory is not intended to stay at
The QEH site—
Prof. SMITH: I can expand on that a little if you like.
654
The CHAIRPERSON: I am just concerned about the time. I am really just trying to
get hold of the magnitude. There was originally a proposal for a second floor on the allied health and
rehabilitation; would that fix it?
Prof. VISVANATHAN: No.
655
The CHAIRPERSON: Okay; so that would not fix it. I think the estimate was that it
was going to be another $20 million, so $40 million would not fix it. We just need to get a feel here.
Let me put it this way, if the move is not viable without a significant increase in investment then
perhaps a move is not viable. That is the point I am getting too.
Prof. VISVANATHAN: So if we have to make a guess then this would be our—
656
The CHAIRPERSON: I appreciate that you are clinicians and not engineers or
quantity surveyors but if any information became available to you, that would help the committee get
an understanding of the magnitude there. Another point is that I think there was a general view that
CALHN CEO, Julia Squire, has been engaging since December and that has been a positive
engagement; I did not really have any feel as to whether, other than a positive environment, there
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had actually been progress in resolving issues. Would anyone care to comment on how far we are
through resolving the set of unresolved issues?
Assoc. Prof. KIROFF: I think Julia Squire has been very positive, and she has done
her best to try to tease out the imperatives and what we see as the impediments to this move. I feel
she is somewhat hamstrung because she feels she is working under the political directive to work
within the current funding envelope, so she has not, perhaps, been as proactive as I am sure she is
inclined to be to try to solve this situation in the best way possible. She feels she has to work within
the political constraints she has been given.
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progress?
The CHAIRPERSON: So the environment is better but we are yet to see tangible
Assoc. Prof. KIROFF: Yes.
658
The Hon. T.T. NGO: I have just a couple of questions. The general feeling I have
got is that pre-2015 the consultation process has been non-existent but since then it has been a lot
better.
Assoc. Prof. KIROFF: Yes.
659
The Hon. T.T. NGO: Some of you mentioned that you have the best facility, an
award-winning facility, at The QEH and one of the reasons you do not want to move is because you
have an existing good facility. But time changes, and if you move and leave the current facility and
build up the new facility down the track, wouldn't it be okay? I just have a feeling that you do not want
to move because the existing facility—
Assoc. Prof. KIROFF: I am sure we all have views on that, but that is not the case.
I don't think anyone is adverse to change. Certainly, within the surgical domain, we have been
working very closely with our colleagues in the Royal Adelaide Hospital to integrate our surgical
services across the two sites. That's already been reflected in moves to take breast and endocrine
surgery onto this site, for example, and to move vascular surgery onto the RAH site, which has
already occurred.
That's going to continue to evolve as we appreciate that there will be inevitable
changes in the sort of acute support that we have in intensive care down the track. As the new RAH
opens, the spectrum of our work is going to change. So, with respect, I don't believe that anyone
sitting here is adverse to change.
Prof. VISVANATHAN: The other thing is the emphasis on the subacute services is
that we are a constellation of services which are interlinked, so there is psychogeriatric medicine,
geriatric medicine, palliative care and rehabilitation. These services tend to be at general hospital
sites, so the correct location and infrastructure takes a long time to build. These are investments that
were part of the strategy for planning.
Prof. SMITH: For respiratory medicine, it just so happens we are on the ground floor.
We don't necessarily have to be on the ground floor, and it probably is more suitable for incoming
Hampstead patients to acquire a ground-floor ward. We are actually completely comfortable with
that. Not only are we happy to move, we want it to be a sensible move, and we are more than willing
to move to the new hospital.
You have got to realise the context. Intensive care at The Queen Elizabeth is being
downgraded from level three to level one—from about 15 or so beds down to two to four beds—so
we are a mismatch. Renal has gone and the neurology ward has gone. Cardiology are quite possibly
not going to get their catheter labs renewed, which knocks out cardiology and coronary care.
It actually makes sense, if you look at this broadly, that, for an acute specialty service
like respiratory, it would be a mismatch to be squeezed into the back corner of some unsuitable, nonpurpose design ward. It's not that we have a reluctance to move or change: we are actually all for it.
We want it to be rational though and well-planned.
660
The Hon. T.T. NGO: Can I just make one more comment? It seems like you all have
a part to play, and Julia Squire has been in consultation with the group. Is there a view that makes
her job a bit easier? It seems like you all have good points on how to move forward and make the
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Friday, 8 April 2016
changes quickly. Is there one general view of how things will be done? Do you see where I am
coming from?
Assoc. Prof. KIROFF: Yes, I do.
661
The Hon. T.T. NGO: You all have good views, I have no doubt about that, but in
terms of moving forward—
Assoc. Prof. KIROFF: I think, on the order of the move, if the political instruction
given to Julia Squire was that we would like to co-locate rehabilitation beds with an acute hospital as
the first order, the second order being that there isn't any need to work within a budget of $20 million
but that budget could be expanded to a reasonable level, and the third order being that the outcome
should be in consultation with both existing sites at Hampstead and at The Queen Elizabeth, I am
sure she could find a solution. That would involve perhaps respiratory medicine moving and providing
a consultative service down here. These things could be resolved.
Dr JELBART: Could I make another comment concerning the timing of such
changes? There is this very large requirement for the new hospital to be transferred—an enormous
exercise—from the other end of North Terrace to the west end. This will require ramping down of
numbers of patients at the old site so that the minimum amount of resources are required to physically
move patients to the western end of North Terrace.
If things go wrong, if there is a seasonal outbreak of some illness, which happens
every winter, causing a drastic overload of all acute hospital sites, then there will need to be a fullyfunctioning and responsive backup service available, which would be The Queen Elizabeth Hospital
in its present form where it is running efficiently and has very well developed clinical pathways and
relationships with other colleagues. To undermine that and dismantle it at such a stage, we believe,
would be irresponsible and potentially catastrophic for patients of this city.
662
The CHAIRPERSON: We will need to bring this part of the session to a close. Could
I ask each of you to take a couple of questions on notice? I should say that one question is just to
one of you. I think Dr Jelbart mentioned AROC, and I think Dr Winsor may have as well. Would you
mind giving the committee a note as to:
x
In what ways do you think the AROC data has been misunderstood?
In relation to each unit—and this will also apply to the units that are going to appear before us
shortly—I ask the following questions on notice:
x
x
x
x
How many beds does your unit currently have?
Does your unit have any forecast of beds that was produced before Transforming
Health?
How many beds do you understand your unit will have after Transforming Health?
Is there any change in service delivery which could account for the capacity to reduce,
or for that matter increase, the beds under the new Transforming Health arrangements?
Of course, it goes without saying that, if there's anything that comes to mind after this meeting, the
committee is always willing to receive additional information. Thank you very much for your
appearance today.
THE WITNESSES WITHDREW
SELECT COMMITTEE ON TRANSFORMING HEALTH
Transforming Health- Parliamentary Select Committee 8th April 2016- Questions
On Notice
Prepared by Professor Renuka Visvanathan
How many beds does your unit currently have?
We would like to acknowledge that SA Health has demonstrated improvement in
service delivery towards older people since the roll out of the Health Service
Framework for Older People 2009-2016 and we have seen improvements for older
people in terms of access to GEM Units, falls prevention programs, outpatient
services, community geriatrics services, orthogeriatric services, rural geriatric services
etc.
The Geriatric Evaluation and Management (GEM) Unit at the Queen Elizabeth
Hospital currently has 28 beds, following an increase in August 2015 by 8 beds from
20 beds. This unit services the Central Adelaide Local Health Network region. In
2015 also, there was a boost to community geriatrics services (i.e. ambulatory GEM
services) in CALHN.
Does your unit have any forecast of beds that was produced before
Transforming Health?
The Health Service Framework for Older People 2009-2016 on Page 21 states that
there is a requirement for 15 inpatient beds per 100,000 population located in the
general hospital (i.e. not the spine hospital). It also states a desired 7 ambulatory
places per 100 000 population.
The Statewide Rehabilitation Plan 2009-2017 similarly discusses this on page 21 and
alludes to the 15beds: 100,000 population ratio for GEM unit inpatient beds and 7
ambulatory places per 100,000 population for GEM services. In Table 6 of this
document, they allude to this ratio having been suggested in Ontario, Victoria and the
AFRM. The rehabilitation plan clearly articulates that there will be rehabilitation
inpatient beds and GEM inpatient beds.
In line with the above plans and framework, SA Health Portfolio Endorsed A Model
Of Care For South Australia’s GEM Units as developed by the Older Person’s
Clinical Network (chair for workgroup Dr John Maddision, Chair of Network A/Prof
Craig Whitehead, Deputy Chair Professor Renuka Visvanathan). The model of care
provides the following estimate on Page 8: CALHN would require approximately 73
inpatient GEM Unit beds by 2021 with 70 estimated for 2016.
The same model of care also provides for the physical environment of the GEM UnitPage 15.
How many beds do you understand your unit will have after Transforming
Health?
“The following has been provided in good faith and to the best of my ability given
data available to me”
We were only provided some length of stay estimates by TH on Wednesday 6th of
April 2016 for the first time. We were told that the current YTD estimate for TQEH
separations are 461 with an ALOS of 17.1 days within the 28 beds. It was being
proposed that we would achieve and ALOS of 15.6 days by 2018/2019 and it is
unclear what this means in terms of bed allocated as yet.
Is there any change in service delivery, which could account for the capacity to
reduce, or for that matter increase, the beds under the new Transforming Health
arrangements?
“The following has been provided in good faith and to the best of my ability given
data available to me”
We treat older patients who are frail and have a mean age around 83-85 years old. We
require the facilities of the general hospital to manage their acute and chronic disease
as well as optimize their health. We have already improved ALOS for GEM Units
from previous values around 22-25 days and we have also moved forward in the care
continuum taking higher acuity patients (i.e. modernized GEM Units).
We are unclear how we will achieve a projected GEM average length of stay of 15.6
days with this cohort by 2018/2019 as estimated by Transforming Health.
We would like to highlight that we have very little allied health staffing dedicated to
our service (a shortfall since 2009). We are awaiting approval of an allied health
business case submitted at the time of increasing our bed numbers from 20 to 28 beds
in August 2015. This is yet to be approved. This is something that is desperately
necessary for our consumers and to assist improve our efficiency. This is one measure
that could improve our efficiency and effectiveness as a service for our consumers.
It has been suggested that realigning acute care beds towards sub-acute care such as
GEM Unit beds will allow us to provide consumer centred care and better meet the
needs of our older patients, especially those frail and aged 80 years and older. It is
apparent that when compared to states like Victoria, access to GEM Units in South
Australia is significantly limited by the number of available inpatient beds in our
system and this is of significant concern in CALHN where we have a significant
number of older people aged 80 years and older and this is set to increase over the
next decade. This is also a strategy that should be considered and would move us
closer to the desired ratio of 15 inpatient beds:100,000 population.
As a service, we also face similar exit blocks to ACAT, care awaiting placement and
transition care programs no different to all other units in our acute hospitals. Any
improvements to any of these systems will also improve flow through our unit. It
should be noted however that many of this programs are at full capacity.
Our average length of stay (ALOS) for GEM from the Health RoundTable Data for
Jan 2015-December 2015 of 17.9 days was similar to the national average of 18.2
days. When the combined ALOS (i.e. acute, GEM and other sub-acute stay) for our
episodes of care were looked at, we performed better with an average of 25.7 days
compared to the national average of 31.6 days.
If we were to take Caulfield General Hospital in Alfred Health as a comparator
hospital, then our GEM ALOS of 18.2 days is lower than theirs of 21.7 days and our
combined ALOS of 31.6 days is also better than theirs of 36.6 days.
The GEM ALOS from HRT data for Jan-Dec 2015 reflects that the GEM ALOS for
Repatriation GEM was 22.2 days and for Modbury GEM was 14.6 days (c.f. TQEH
GEM of 17.9 days). The combined ALOS for Repatriation GEM was 38.9 days and
for Modbury GEM was 26.7 days (c.f. TQEH GEM of 25.7 days). The acute ALOS
pre GEM was 13.9 days for SALHN (Repat GEM), 9 days for NALHN (Modbury
GEM) and 6.9 days for CALHN (TQEH GEM) [please note national average was
11.3 days with Alfred Health being 14.4 days].
Friday, 8 April 2016
Legislative Council
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WITNESSES:
MARSHALL, RUTH, Medical Director, South Australian Spinal Cord Injury Service
PRICE, TIM, Head of Haematology and Oncology, The Queen Elizabeth Hospital
HOROWITZ, JOHN, Head of Cardiology and Clinical Pharmacology, The Queen Elizabeth Hospital
DHILLON, ROHAN, Head of Psychiatric Services, The Queen Elizabeth Hospital
CHEHADE, MELLICK, Orthopaedic and Trauma Surgeon, Royal Adelaide Hospital
JELBART, MIRANDA, Medical Director, South Australia Brain Injury Rehabilitation Services
SMITH, BRIAN, Director of Respiratory Medicine, The Queen Elizabeth Hospital
663
The CHAIRPERSON: I understand that not all of you were present at the beginning
of the meeting, so I feel the need to both welcome you and make you aware of the following. The
Legislative Council has given the authority for this committee to hold public meetings. A transcript of
your evidence today will be forwarded to you for your examination for any clerical corrections. Should
you wish at any time to present confidential evidence to the committee, please indicate and the
committee will consider your request.
Parliamentary privilege is accorded to all evidence presented to a select committee.
However, witnesses should be aware that privilege does not extend to statements made outside of
this meeting. All persons, including members of the media, are reminded that the same rules apply
as in the reporting of parliament. I will introduce the people on the committee. Susan Markotic is our
research officer. The Hon. Tung Ngo is a member of the committee. My name is Stephen Wade and
I am the Chairperson. Mr Guy Dickson is our secretary. We are also joined by Hansard.
I understand there's more than one person who would like to make a statement, so
if I could ask you to make a statement and we will hold any questions that we have to any of you until
the end. I understand Associate Professor Ruth Marshall will start. As I understand it, we are going
to progress left to right. I don't know to what extent witnesses were here for the first session, but
please take the first session as read, so any information provided there is available to the committee,
but we will be delighted to hear what you would like to share with us. Thanks, Associate Professor
Marshall.
Assoc. Prof. MARSHALL: My name is Ruth Marshall and I am a rehabilitation
physician. I have worked in rehabilitation medicine since the late 1970s. I have been the Medical
Director of the South Australian Spinal Cord Injury Service for 30 years come 5 May this year, which
is a very long time, and I have seen a lot of changes. I have also been involved in the move of the
spinal unit from its original site, where they moved from the Royal Adelaide Hospital in 1962 into
temporary accommodation, into more permanent accommodation in 1994, which was opened by
Michael Armitage.
I am also the academic lead for rehabilitation medicine at Adelaide University, and
as such have a teaching and research role. I cannot state that I have as many research grants as
some of my colleagues in this room, but in rehabilitation medicine and spinal cord injury medicine we
have held over the last 20 years more than $20 million in research grants.
Having worked in rehabilitation medicine for so long, and specifically in spinal cord,
I am very aware of the needs of people who have developed significant mobility impairments in
particular. The South Australian Spinal Cord Injury Service is a statewide service that looks after
people who live in South Australia, western New South Wales, the Mildura region of Victoria, and the
whole of the Northern Territory. I like to say that we look after the middle third of Australia from top
to bottom.
We hold outreach clinics in various areas of South Australia, predominantly
Mount Gambier and Whyalla, and we hold outreach clinics in Alice Springs, in Darwin, in Katherine,
and in East Arnhem on a skinflint staffing level. Thankfully, the Northern Territory has spinal nurses
who support that process.
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You asked about the cost of a move. I can't tell you how much a move to this site
from Hampstead will cost, but in 1993-94 it cost almost $5 million to build a therapy building, move
and enlarge the gym (which is actually a tin shed, but we moved from having a concrete floor to a
wooden floor), and refurbish two wards to create one large ward for the spinal unit. We have 25 beds,
21 of which are commissioned and four are unfunded, but we run on 95 to 100 per cent occupancy
all the time.
Dr Jelbart did not mention that one of the plans as part of the new Royal Adelaide
Hospital is to move six of the spinal cord beds and six of the brain injury beds to the new
Royal Adelaide Hospital to create a neurotrauma rehabilitation unit that will facilitate fast-stream
rehabilitation for people with mild spinal cord injuries, for people who are on ventilators who need to
start their rehabilitation and for people who have cancer; they need to have their cancer treatment,
and taking them from site to site is really not in their best interest, so we'll be able to provide them
with spinal cord injury rehabilitation at the new Royal Adelaide Hospital.
I was concerned, however, at a meeting on Wednesday, when a representative of
Transforming Health said, 'Of course there will be 12 rehab beds going at the new Royal Adelaide
Hospital', suggesting to the room that they were general rehabilitation beds, when in fact they are
very much specialist rehabilitation beds that are taken from spinal cord and brain injury rehabilitation
services.
Transforming Health has utilised again AROC benchmarks that are not supposed to
be utilised in this way, and we will provide you with documentation to explain about that centre—
because we would take up the whole day just talking about it—to say that in fact the spinal cord injury
service only needs a total of 18 beds, six at the new RAH, and 12 at The QEH. They're going to give
me a 16-bed ward cobbled together out of respiratory and pall care to create a new spinal unit with
16 beds, but four of those beds are actually going to be for general rehab, which makes no sense to
anybody and it certainly doesn't make sense to me, given that I have 25 beds at the moment that are
constantly full.
The surgical people have every right to be concerned, because they know that I will
not be able to take the post pressure ulcer patients who have had surgery to repair and reconstruct
their skin, which is a major problem for people ageing with a spinal cord injury. They know that I will
leave those patients in their beds and tell them how to do the sitting programs because I will not have
beds to take those patients in this much smaller unit.
I am desperately concerned about how we will also manage the re-referrals from the
community because, unlike people who have had a fractured hip, my patients are ageing with a
spinal cord injury and, as they get older, they develop respiratory problems, cardiac problems,
fractures, pressure injuries—you name it, they get it—and it is as a result of this spinal cord injury.
They cannot be managed in a general rehab unit; they get referred to me and Dr Winsor is pushing
me to take one of my patients who is currently in his ward, but we do not have a bed. So we are full
but we are told that we will be able to manage with fewer beds. I am not sure how we are supposed
to do that, Mr Wade.
There are a couple of other things that I wanted to talk about. It took me 15 minutes
to park here this morning with Dr Jelbart. Thankfully, we only brought one car and not two, but it was
very frustrating. You will hear from Dr Dhillon about parking at Hampstead. There are only
20 wheelchair accessible parks here; at Hampstead we have more than 65. We are going to move
a lot of staff, patients and their families to this site with no additional parking space; in fact, I think
less parking space because they are going to be building into the car parks.
Professor Visvanathan talked about the mobility gardens that she has. I looked at
those gardens the other day but they are not really wheelchair accessible unfortunately. The garden
space that is supposed to be for the new spinal unit runs off the respiratory unit high dependency
four-bed bay which is going to be turned into a dining room. It is actually not big enough for the dining
room and almost falls onto the nurses' station, which is not really appropriate for a dining room. The
outdoor area from there is a concrete slab.
My patients are currently able to access green, grassed areas which are wheelchair
accessible. They need to be able to learn to use their wheelchairs without running over other people.
The main corridor in the north-south ground is a main thoroughfare for the hospital. I think it is going
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to be very unsafe for people in spinal units, in wheelchairs, on barouches, etc. and I do not know
how that is going to work.
I had not seen that ward until last week because I was not allowed to. The architects
were not allowed to go inside the ward to have a look, so they looked at developing the plan without
actually seeing what was there. I had to convince them and show them physically why the current
bathrooms in those wards are not wheelchair accessible for people using complex shower
commodes who may need three or four people to wash them; therefore, the cost of refurbishing the
ward to make it wheelchair accessible for a spinal unit means that we have to spend a lot of money
on redoing the bathrooms, and the architects have said that that is the case.
I think the way that they are planning this is crazy. I think it is crazy because we are
moving into wards that are purpose-built at a great cost and I think it will cost a lot more to make it
right. I do not understand why they just cannot build us a new ward.
Prof. PRICE: I am Tim Price. I am the head of the combined haematology/oncology
unit and of the Clinical Cancer Research unit at The Queen Elizabeth and the lead for the
Translational Research Program here at the Basil Hetzel. I am a medical oncologist and have been
at The Queen Elizabeth Hospital for 16 years. I guess I am here for the cancer unit which is a service
which provides a number of different care pathways for the community, including medical oncology,
solid cancer therapy and haematology, and we also oversee the management of some of the
radiation patients who come from elsewhere.
Like others, I guess the first thing to note about our unit is that we support the
appropriate planned and financed improvements to services. However, for the cancer service, our
concern is the impact of our service delivery in this region. Coming back to your question about
whether moving is a concern, the actual state cancer plan, of course, guides us and drives us to
provide cancer care, chemotherapy and so forth to the community, so moving for us does not make
sense. It is in keeping with the state cancer plan that we do not move but we provide care locally.
Currently, the data shows that we do this. We have over 2,000 separations a year,
mostly from this community, so unlike the RAH we actually serve the community. We have an
internationally recognised research output. Again, the state government is very keen that we have
active research into cancer care, and access to the new trials of new drugs is crucial. Again, having
that locally is very important.
Simply put, for us, the major impact of this Transforming Health process is the
ongoing uncertainty and the ongoing lack of communication, and the lack of clear planning, for our
service. The message of displacing or reducing our successful and productive service does not make
sense to us. We have been held back in terms of how we move forward and, although we understand
the need for rehabilitation to move here, displacing our service, as I say, does not make sense.
You asked a question about beds. We have 21 beds at this site, and one of our
concerns is that I cannot answer the other question because we have been given no guidance as to
what our bed numbers will be. Therefore, our strategy and how we move forward, cannot proceed.
For a cancer service to function, we need ambulatory care clinics. We obviously need chemotherapy
chairs and the trained staff to man those for safe delivery of chemotherapy, and we need the inpatient
space to look after these patients when they get unwell either from their therapy or from their cancer,
and that needs to be done locally for continuity of care and productivity and safe care. We see no
benefit to the state or to the region or to this local community in dismantling this service purely to
allow a shift. We understand the drives behind rehabilitation expanding on this site, but closing down
an important service does not make sense.
Prof. HOROWITZ: I really appreciate your being able to undertake this evaluation. I
cannot say how regretful I am that it is necessary. I think we should start off by saying that the crux
of this problem is neither the move of the rehabilitation hospital to The Queen Elizabeth nor The
Queen Elizabeth itself. The crux of the problem is the new Royal Adelaide and its economic
consequences, which I see as a sort of economic tsunami which has been slowly rolling towards The
Queen Elizabeth for five years while the response by our political masters has been to teach us to
live under water.
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Let me start off with what my credentials are. I am Head of Cardiology and Clinical
Pharmacology at The Queen Elizabeth. I am one of only three people in Australia with such dual
qualifications. I have been here for 27 years. During 15 of those 27 years I also functioned as the
head of cardiology at the Lyell McEwin. I hold professorial positions at the University of Adelaide and
also at the University of South Australia and the University of Aberdeen, where I spend a number of
periods of time.
Cardiology at The Queen Elizabeth has historically been by far the largest medical
unit, indeed the largest unit, at The Queen Elizabeth and it still is. It also has had the largest research
productivity, and we have collaboration with several countries around the world. We have brought in
in excess of $30 million worth of research funding over the period of my tenure. We have produced
more PhD students than any other unit at The Queen Elizabeth Hospital, and these PhD students
have been medical, science, nursing and pharmacy based.
We have the only unit in Adelaide which has a compulsory academic program, so all
cardiology trainees wind up also as research trainees. Many of my trainees are now professors and
heads of units elsewhere.
With that background we have two problems. Firstly, all of the compressive effects
of the movement into a hospital is sort of like the foot motif in Monty Python where a giant foot lands
on a structure and compresses it. That is about the level of that. But there is also the idea that every
aspect of cardiology should fit into the new RAH. It is like a mantra—the new RAH is a hospital of
infinite capacity which can accommodate all forms of acute medicine. Let me tell you, that threatens
every hospital in Adelaide.
The current Royal Adelaide has 48 cardiac beds on average. Some of those are
monitored by cardiologists (31 of them) and the remainder are monitored by general physicians,
which itself is a scandal. They are being told that they will have 29 cardiac beds at the new RAH. Not
only that, but those 29 cardiac beds, as of last Thursday, were to serve every cardiac patient between
the current RAH and the current Queen Elizabeth where we have 30 beds. How this is to be achieved
is through greater efficiencies of patient care. That, in my opinion, is a gross act of negligence.
For example, three months ago the Royal Adelaide Hospital were told that they were
admitting too many patients with heart attacks and next year they should halve the number of patients
admitted with heart attacks—an interesting exercise. This gives me some idea of the nexus of
understanding between the bureaucrats and the clinicians. You ask: how often are the clinicians
asked? I have offered my advice to the minister repeatedly for two years and I have had no reply to
that, largely because I chose to insult the idea of the new RAH in terms of concept and location when
it was first suggested.
Until last Thursday, the official number of cardiac beds to be available at
The Queen Elizabeth Hospital from January 2017 was zero—a sort of economic/clinical version of
ethnic cleansing. We are in the epicentre of cardiac disease in South Australia—the western suburbs.
There is no higher concentration or more cases. We have a well-functioning, cost-effective and worldfamous cardiac unit and some idiot in the health department has made the decision that we are to
be compressed into a total of less than half the number of cardiac beds currently available between
the Royal Adelaide and us. I think that is unjust and poor planning.
I have prepared a very brief handout. I will not have time to go through everything.
Let me throw out a few copies of this just touting our credentials. I am not going to go through all of
that, but the key thing is that the major problem in South Australia, as far as health is concerned, is
that they are running out of money, and in that situation I would emphasise the fact that, despite
having academic objectives, we are extremely cost-effective.
It costs somewhere around $1,500 less per cardiac patient to manage a patient at
The Queen Elizabeth Hospital than at the Royal Adelaide. You say, 'Is this second degree
management?' No. We have a lower readmission rate, a shorter length of stay, a lower complication
rate, and for heart attacks a lower mortality. I am about to show you those figures. Indeed, the
Royal Adelaide has the highest mortality in the state.
I would not be trumpeting this from the rooftops except that Dorothy Keefe has gone
public saying that it would be better for ambulances to go up Port Road, past the roadworks and up
to the Royal Adelaide with all of their heart attacks and they will do better. I dispute that. They will do
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worse. A few would die and a whole lot will have larger heart attacks than they need to because of
the delay.
We have been world leaders in the development of a number of things. We pride
ourselves on being leading researchers in heart disease in women. This is a very important issue
because 50 years ago ischemic heart disease was 80 per cent men. Now it is an equal opportunity
disease because the population is older and it is about 45 per cent women—and women get heart
disease for different reasons—and we are good at it.
We have been at the forefront of developing understanding of new forms of angina.
When I say 'new', of course, they've been around for years but we've been obsessed with exertional
angina, and it turns out there are many other forms. We are also world leaders in something called
takostubo cardiomyopathy—which is the idea that, in women, you can get something that looks like
a heart attack after intense emotional stress such as a bereavement—and a great number of other
things including heart failure, atrial fibrillation. We hold a number of patents and, as I say, we have a
very large research infrastructure.
Our infrastructure is purpose-built and well coordinated. It extends from the door of
the casualty department through to two cath labs which do over 2,000 cases a year. Initially, we
thought we were just trying to protect our cath labs. It turns out we are trying to protect everything—
the whole ethos of the place. I really abhor the idea that The Queen Elizabeth is being slowly torn
apart. The loss of the renal unit here was a tragedy, in my view. It was world famous here; it is not
doing so well at the Royal Adelaide.
Above all, the Royal Adelaide cannot be a vessel of unlimited capacity. It cannot
accommodate everything, as everyone is well aware. It is a medium-sized hospital which will be very
expensive to run. It is masquerading as a high turnover hospital by virtue of having a fleet of
ambulances running up and down Port Road, so it can say, 'We can do eight-hour admissions. That's
an admission. What do we do afterwards? We decamp the patient to The Queen Elizabeth.'
What is the problem about this? No cardiac beds at The Queen Elizabeth. The
planning process is derelict. As of last Thursday and the minister's visit, there is no planning process
at all in the sense that we do not know how many cardiac beds we've been allocated. It's officially
beds in revision. This is a very sad state of affairs six months before the new Royal Adelaide is meant
to open.
I'd like to close with one last thing, because I feel I have been maligned badly here.
I'd like to hand to each of you a copy of these VLAD figures and they'll take a while to look at. There
are two graphs, one on each page. This is a series of lines dating from 2012 to 2015. There is a
central line here which, if you are on zero, means your mortality for heart attacks is about the same
as the rest of Australia. If you're above that, you are saving lives. If you're below it, you're worse.
You're looking at the Royal Adelaide figures. In the series of lines you've got, there's
a central bold line which refers to your actual mortality and the lines around it are the 50, 75 and 95
per cent confidence limits on how you are doing. You can see that the Royal Adelaide Hospital
spends most of its time below that line and, on several occasions, it dips to 4 per cent and
occasionally 5 per cent increased mortality relative to the national average. This is not what I would
call a leading cardiac hospital.
On the other side, you see The Queen Elizabeth mortality from that period of time
and you can actually see that The Queen Elizabeth basically does better throughout that period of
time. It does at one stage go to 4 per cent decreased mortality and never goes above. Royal Adelaide
has gone to 4 per cent above quite frequently. This is to say that we have, if anything, a lower
mortality throughout that four-year period for heart attacks than the Royal Adelaide.
I do not see how it can be claimed that moving patients out of our cardiac unit where
they do better, are managed more cheaply and have a lower readmission rate—all of the things that
are economically extremely desirable in this dangerous time—how can it be good to actually
terminate, or even reduce in any way, the activity of such a unit?
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The CHAIRPERSON: Thank you, Professor Horowitz. Associate Professor Dhillon.
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Assoc. Prof. DHILLON: Thank you for this opportunity to speak to the committee.
Just by way of my background, I am an associate professor of psychiatry at The Queen Elizabeth
Hospital. I also currently hold the position of Head of Psychiatric Services at The Queen Elizabeth
Hospital. Previously, I was the clinical director of the Western Mental Health Service, but that position
dissolved at the start of this year.
I have been at The Queen Elizabeth Hospital as a doctor for 28 years, since I started
as an intern in 1988. I did my training in psychiatry at The Queen Elizabeth Hospital, and I have been
a specialist at this hospital for 22 years in psychiatry. In relation to your question about change in
psychiatry, we have had to deal with a lot of change during my time in psychiatry.
There used to be two state mental hospitals, Glenside hospital and Hillcrest hospital.
In 1998, Cramond Clinic at The Queen Elizabeth Hospital was the first hospital to mainstream in
South Australia, meaning that all the acute beds at the state mental hospitals were closed, and a 40bed unit was built here at The Queen Elizabeth Hospital. In the last 10 years, we have had 19 acute
psychiatric bed closures, and so Cramond Clinic has gone from a 40-bed unit to a 21-bed unit.
No other metropolitan hospital in Adelaide has had that degree of acute bed
closures. That has had a significant impact on wait times to access a bed from the emergency
department and bed block, so we were quite pleased and welcomed the minister's focus on mental
health and his stipulation that he did not want any mental health patient waiting more than 24 hours
for a bed in an emergency department.
With that, he made an announcement to commission eight short-stay unit beds here
at The Queen Elizabeth Hospital, which was welcomed by all the clinicians and staff, because we
felt there were too many acute bed closures in the last 10 years. Unfortunately, the first experience
with Transforming Health and the whole consultation process was the location of this short-stay unit.
Because of the minister's imperative that starting on 1 January 2016 no mental
health patient will be waiting in an emergency department for more than 24 hours, there was a lot of
activity to look at locations within The Queen Elizabeth Hospital for the short-stay unit. I, as the
western clinical director, was involved in looking at a few sites, and one of the sites that we actually
rejected was the North East 2 Ward on the second floor, which is quite dislocated from the emergency
department and Cramond Clinic.
Unfortunately, despite the team saying it was an inappropriate site, that site was
chosen to put the short-stay unit, which is now currently on the second floor and quite dislocated.
Clearly, it is not a short-stay unit; so, even though we welcome the eight additional beds, we do not
have a short-stay unit. We have a step-down unit that we are trying to manage the best way we can
to meet the demands from our emergency department.
We were told the decision was made by the CEO of CALHN, and I was quite
disappointed, as the western clinical director and the senior psychiatrist, not to have any say in the
location of the short-stay unit. In response, the western psychiatrists have recently written a letter to
Julia Squire, the CEO of CALHN, basically outlining that we would like a short-stay unit similar to the
Flinders Medical Centre, colocated next to the emergency department. We feel that this would be
the ideal location that would really allow us to provide good care for our patients and create a more
efficient service, and meet the targets that the minister has stipulated.
The other major area of concern has been that, with the closure of Cramond Clinic,
the psychogeriatric services were basically used in the space that was part of the bed closures, but
it has been ridiculous. The beds that are for eastern and western consumers (or clients or patients)
are being run by the Northern Adelaide Local Health Network. Even though it is located at The Queen
Elizabeth Hospital, the transition from NALHN (which is the Northern Adelaide Local Health Network)
to CALHN still has not happened, and there is a lot of confusion.
My understanding is that there have been four bed closures to allow this transition
to happen at some point this year, because of money issues. That does not make sense to me, in
an ageing population where there is a demand for psychogeriatric beds. That is another area of
concern as part of Transforming Health.
The last thing I wanted to talk about, because I know there are time constraints, is a
more personal experience that Ruth Marshall mentioned. Ruth is actually the consultant that is
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looking after my father, who suffered a spinal injury in October last year when he fell in his garden
and had a C2 fracture. He has been at the Hampstead Rehabilitation Centre for several months
undergoing rehabilitation.
My mum, who is an 80-year-old woman, is quite frail and uses a walking stick, but
actually drives every day to see my dad at the Hampstead Centre. He doesn't like the hospital food,
and so she brings him food every day. She can park very easily and go and visit him, and the walking
distance is quite minimal. We also visit him quite regularly. I cannot imagine how my mum would
cope having to drive to The Queen Elizabeth Hospital when my private patients also have to drive
around and be late for appointments before they come and see me for a consultation. So, again, the
whole idea about consultation space is very significant in my mind.
Assoc. Prof. CHEHADE: I am going to bring a slightly different perspective to it. I
am an orthopaedic and trauma surgeon and I work at the Royal Adelaide Hospital, where my role as
a trauma surgeon is largely involved, these days, in dealing with older patients with fractures and
injuries. That includes hip fractures that may be able to be fixed or they might require joint
replacement, any number of things.
The key point that I really want to bring out is that our health system will not work
properly and efficiently if we do not get the balance, the numbers, right between acute and subacute
care and rehab. The current numbers I am seeing, and the planning, is going very much against what
you would see as ideal, best practice and efficient care. That is one message.
The other thing relates to the timing. We are going to have an iconic move of the
new Royal Adelaide Hospital with a lot of uncertainties, and to try to speculate exactly what sort of
numbers are going to be required in different areas and what is going to happen with acute care or
subacute care is almost impossible—especially given the delay with the new Royal Adelaide. So I
think any attempt to do this should happen once the new Royal Adelaide has had a chance to
implement.
We need a safety valve with The Queen Elizabeth to be able to ramp up/ramp down,
or whatever is required, until the dust has settled. Then you can start looking at the numbers carefully,
and looking at those numbers in consultation with experts who understand the numbers, who know
the real situation—both current and emerging.
Going back to my role, my major research interest has been in osteoporosis and hip
fractures, and doing better trauma care. I have been able to set up what has really been an
international first with fracture outcomes across the spectrum, and our database at the Royal
Adelaide has now informed both national and international changes and standards. I have worked
with the Australian Commission for Safety and Quality and, as you know, hip fractures have become
a major issue; we can understand the economic and social impact that is having.
So it is being involved with the development of those guidelines, the development of
the standards. At an international level my role has been with the Bone and Joint Decade, which is
now linked with the World Health Organisation, about how to build capacity and to implement best
models of care that are going to deliver the best type of, best quality and most efficient care, and I
am very fortunate to actually be leading that task force.
What I am going to try to do is just quickly bring the experience of the Royal Adelaide
into context with what are best models of care. From an acute point of view we have the standards,
and we want to get patients to theatre as quickly as possible, through the emergency department,
and we need an ortho-geriatric model of care where geriatricians are involved with the management
as well. They need to get into surgery. International standards are 36 hours and Australian standards
are 48 hours; we have managed to achieve less than 24 hours at the Royal Adelaide Hospital. We
are doing the type of surgery that has been presented now internationally as being way on top of the
list of where our outcomes are.
For all of this, our length of stay, looking at the round table, is poor. I can say that at
the moment—if we are going to use a general surgeon's language—we are severely constipated.
With the changes that are about to be introduced we are going to go into a total bowel obstruction. I
can't think of any better way to put it.
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Within three or four days, the majority of our patients are sorted from a surgical point
of view and in liaison with the geriatricians on our service, but then they hang around for several
more days in very expensive, acute-care beds getting suboptimal treatment whilst they are waiting
for further geriatric evaluation or to move to rehab beds, etc. They need subacute care and that
means particularly geriatric services at a geriatric evaluation and management (GEM) unit.
At the Royal Adelaide, we don't actually have access to the GEM unit, so not only is
it more expensive, not only is it contributing to our increased length of stay, it is actually not delivering
the necessary care. If you were to transfer them into a GEM unit, then they are going to be
appropriately coordinated with the necessary physicians who are involved. They will be coordinated
by a geriatrician, but it might require the oncologist or it might require the respiratory physician, the
cardiologist or the rehab physicians, etc.
If you have a look at the chart, there is a misunderstanding, I think, in the community
that hip fracture patients are hip fracture patients, and they are one group; however, they are an
incredibly diverse group. At one extreme, you have people who are falling because they are very
healthy, ageing individuals. They are out there walking their dogs and playing with their
grandchildren, and they are unfortunate. They have a slip, they trip, they fall and they break their hip
or something else.
They come into our services, they get very rapidly processed and treated and then,
hopefully, they can go home, sometimes with some home in the care rehab but it doesn't really
matter. They are probably 25 per cent of the group that we are dealing with. At the other extreme,
you have those patients who are already almost palliative. They are in nursing home care. They are
getting a lot of special care already and have limited goals. They come in, and then, largely, they can
be returned to that environment quickly.
But increasingly, there is this middle group which is probably around about
50 per cent, and this is the growing number. These are the ones who are just on the edge at home,
just coping. They have multiple comorbidities. They are socially disadvantaged. There is the tyranny
of distance and mobility in transport, or they have just gone into low-level institutional care where
they don't have the additional supports.
This is the group, this expanding group, that needs access to those immediate
subacute care services, integrated with the acute care, in order to be able to get more efficient and
better outcomes from us. We know from the literature that quality care in this group is actually much
less expensive—that's very, very well documented. There are health economic factors that say, if
you do this properly, it will in fact drive your costs down.
I think I have said all I really need to. I think it's fairly clear. If we are going to move
to the goal of Transforming Health, which is patient-centred, integrated care where we are looking to
be able to deliver the services as close to the patients as we possibly can, then surgery needs to be
able to link in much better with subacute services and others, and there needs to be much better
consultation around how to do this.
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The CHAIRPERSON: Thank you all for your contributions. I might pick up on the
point that Associate Professor Chehade made in terms of timing. Parliament's Public Works
Committee was told that the construction at The Queen Elizabeth would start in January 2016 and,
obviously, that's passed. Is there a current anticipated start date?
Assoc. Prof. MARSHALL: It's been indicated to me recently that they are going to
start building the pool, the very inadequate therapy space and the spinal unit in the very near future,
but I don't have a date on that and I can't understand why they would do that, really. There is a need
for a hydrotherapy pool on this site, without a doubt, regardless of whether Hampstead Rehab Centre
moves or not, but they have increased the footprint of the original design because they think that that
will meet the needs of the spinal unit, but it still doesn't.
There is no gym space in there for any sort of recreation. They have got an office for
all of the therapy staff to be able to look onto the physio area and phys. ed. area, which will have
seating for four people and it's estimated that 17 people will be using that office. So, there are still
major problems, but we have been told that they were planning to start this financial year.
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Prof. HOROWITZ: I think that effectively there's a state of impasse between the
planners and the staff at this moment. The nature of the move, the timing, in fact all of the details,
are not agreed and I don't think any firm date can be placed on it at the moment.
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The CHAIRPERSON: If I could reiterate the questions I asked your predecessors,
the first group, to take on notice in terms of beds and forecasts, if you wouldn't mind taking them on
notice. Also, I asked a general question, whether any of those members had a thought on how much
it might take beyond the 20.4 that's been committed, or 22, whichever figure you want to use, to
actually make QEH fit for purpose for both the current services and the Hampstead services. I don't
know whether any of the current witnesses have any feel for that.
Assoc. Prof. MARSHALL: I think that the cost of moving Hampstead and getting
back any refurbishment or moving any wards on this site, my estimate is in the vicinity of $40 million—
$35 million to $40 million to do it properly. That is either moving into current wards, but providing
proper therapy space for both brain injury and spinal cord injury, but also recognising that for general
rehab, the space that is currently in use in the therapy building is actually not adequate to take on
43 beds worth of general patients, general rehab. That doesn't take into account moving pall care,
moving oncology, etc., just in terms of Hampstead, and maybe creating a parking area as well.
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The CHAIRPERSON: That would be all three—spinal, brain and general injury?
Assoc. Prof. MARSHALL: Yes, but I think just to do that properly it would be in the
vicinity of $40 million. If we take into account that to move one ward in 1994 and to build a therapy
building it cost $4.6 million, and in 2000 to move the brain injury unit back to Hampstead (it had
moved in 1986 to the Julia Farr) it cost $5.5 million; that's 15 years ago. We are talking about a much
bigger move, not 20, 28 or 25 beds; we're talking about close to 100 beds.
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The CHAIRPERSON: Any thoughts on costs?
Dr JELBART: I would just like to say that there is a precedent where we could look
for comparison, which would be in the Southern Local Health Network for the purpose built and
purpose designed 55 bed rehabilitation service that is now being constructed on the acute hospital
site at Flinders. I would think the ballpark figure to create a purpose-built state-of-the-art centre of
excellence for all of these services could at least be comparable with that figure—you know, making
allowances for differences and possible economies on this site.
Assoc. Prof. CHEHADE: And that was?
Dr JELBART: 155.
Prof. HOROWITZ: So, we are really guessing between 100 and 120, but that would
be a true figure.
Prof. SMITH: The domino effect does extend to the new hospital as well under the
single service approach for respiratory to be relocated to somewhere in the new hospital. We have
a pool of 35 nursing staff, about 10 admin, 10 laboratory, 15 medical, and some infrastructure
associated with it, none of which has actually been thought through yet in terms of housing all of
them or the retrofitting costs associated with it, for example. We've got three TV rooms now, none of
which have been incorporated into the planning at the current Royal Adelaide. It costs about
$50,000 to refit a room so it's suitable for TV: double door entry, negative air filtration, and so on.
Assoc. Prof. MARSHALL: Can I just add that there is an additional issue that we
haven't mentioned about this site. The current outpatient facilities in the tower block are not
wheelchair accessible and, in fact, I know that my colleagues in orthopaedics, geriatrics and palliative
care have had problems with seeing patients in the current outpatients area because they are so ill
suited for people with any sort of mobility impairment to get in there with a wheelchair.
When we had our first meeting last year in August about moving the spinal unit here,
I asked, 'Where are we going to put outpatients?' and I was told that I didn't do outpatients. Between
spinal, brain, stroke, orthopaedic rehab and amputees, we actually do a large number of outpatient
clinics every week at the Hampstead Rehab Centre, and they're only just starting to look at what the
needs are for outpatient clinic space because there is actually nowhere on this site that is suitable to
take our patients.
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The Hon. T.T. NGO: I don't have a question but as a western suburbs person I would
like to thank you all for coming and thank everyone for your service all these years. You have served
the community very well.
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The CHAIRPERSON: It would be fair to say that a meeting doesn't go by without
Mr Ngo reminding us that he's a western suburbs man. Thank you very much for your attendance
today and, as I said to the previous group, we look forward to your responses to questions on notice,
but if there's any other information that you think would assist the committee we would certainly
welcome it.
THE WITNESSES WITHDREW
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