Tasmanian Catholic Justice and Peace Commission
Bringing about change by actively challenging injustice and promoting peace
A Submission To
The New Royal Project
SOCIAL ISSUES and OPPORTUNITIES
Department of Health and Human Services
Submitted by
The Tasmanian Catholic Justice and Peace Commission
November 2008
GPO Box 62, Hobart, 7001
Email [email protected]
Phone (03) 6208 6271
Website www.tasjustice.org
Fax (03) 6208 6299
1
Introduction to the Tasmanian Catholic Justice and Peace Commission
The Tasmanian Catholic Justice and Peace Commission was formed in 1992
and is responsible to the Archbishop of Hobart. There are a maximum of 11
Commissioners appointed by the Archbishop. The Commission meets formally
five times a year.
Its aims and objectives are:
To promote understanding and awareness of Catholic Social Teaching,
particularly in the areas of justice, peace and ecology, and to assist the
people of the Archdiocese to better integrate this understanding within an
evolving Christian lifestyle.
To support and develop critical thinking and social action skills in
parishioners.
To work in a collaborative way with Church and outside organisations in
research, social analysis, social action and prayer to promote social
justice in Tasmania.
To advise the Archbishop and the wider Catholic community in Tasmania
about social justice issues.
To engage in research and analysis of current social justice issues,
including policy preparation.
2
Background
We are all one people, each created in the image and likeness of God. The justice we
render to one person is justice we render to every human being – and to Christ himself.
That sense of universal relationship is at the heart of Christ’s compassion and healing –
the example he gave his disciples throughout his public ministry.
1
When we live in a seemingly affluent society with economic prosperity and
people have inadequate access to healthcare, this is an injustice. It is not an
issue of ‘charity’. ‘When we attend to the needs of those in want, we give them
what is theirs, not ours. More than performing works of mercy, we are paying a
debt of justice’2. This is the basis of argument from which policy should be
derived. Eradicating poverty is not an act of charity, it is doing justice. The social
teachings of the Catholic Church include the principles of human dignity and
promoting the common good. Access to health care maintains the dignity of the
individual and improves the common good of society, physically, economically
and spiritually.
The Tasmanian Catholic Justice and Peace Commission (TCJPC) is primarily
concerned with the issue of equitable access in regards to both the new Royal
Hobart Hospital (RHH) and the current health care system in Tasmania. Access
to health care is not a privilege but a right.
1
Australian Catholic Bishops Conference (2008) A Rich Young Nation: The Challenge of affluence and
poverty in Australia, p.7.
2
Saint Gregory the Great, Regula Pastoralis, 3, 21: PL 77, 87: “Nam cum qualibet necessaria indigentibus
ministramus, sua illis reddimus, non nostra largimur; iustitiae potius debitum soluimus, quam misericordiae
opera implemus”.
3
The 2004 Richardson Report highlighted the various difficulties within the
Tasmanian public and private hospital systems in great detail. It stated that the
public system is performing poorly on a number of key indicators. The current
RHH is a ‘pertinent example of the decline’ of that system.
The aim of a new tertiary level hospital is to remedy many faults of the current
system. Unless the new RHH is constructed within a model of state wide services
improvement, the endeavour will be fruitless. ‘The hospital system will only be
efficient if there is coordination between both the different levels of hospital care
and between hospital, primary health care, and other ambulatory services’.
Whilst the new RHH has been designated as the single tertiary level hospital in
the state, without structural change of the system, equitable access will continue
to be an issue. An effective system would be one in which the RHH provides
general services to the South and complex services to the whole state, with LGH
and the North West Regional Hospital (NWRH) providing general services only to
their populations and looking to RHH as the next level. This would be a united
system for all Tasmania. Given universal access is not possible in practice,
creating equitable access must be a paramount consideration. In order to
achieve equitable access for all Tasmanians requiring tertiary care, services and
facilities at the new RHH and its surrounds must be developed and improved
from the current state of services.
4
Defining Access
Access to ‘enough’ medical care is a right under the United Nations Universal
Declaration of Human Rights (Article 25). ‘Enough’ medical care implies
equitable access to care. However, the term ‘equitable access’ is a much used,
but ill defined expression. At a fundamental level, there is a lack of agreement on
what it actually means and how it is measured. Arguably ‘this lack of consensus
on the definition and operationali[s]ation of the concept has hampered progress
in generating and applying knowledge to identify and strengthen pathways
between access and health outcomes’.3 In terms of policy making, ‘the absence
of a commonly accepted specific definition of ‘equitable access’ is problematic,
because governments are left without a reference point against which to judge
the consistency of their health care policies’.4
The word ‘access’ has many facets. ‘It can mean the time it takes to travel to a
services location under normal circumstance; the time it takes to receive
treatment in the case of accident or sudden illness; the ease with which family
and friends may visit the patient to offer support; or the waiting time to receive
treatment for non-emergency needs’ (Rural Resources Unit, 1994). It should also
mean no group is discriminated against in access. This is equitable access. ‘The
importance of equitable access to services cannot be overestimated’5.
Differences in access to health care can have far-reaching consequences.
3
Equitable Access to Health Care and Infectious Disease Control: Concepts, Measurement and
Interventions Report of an International Symposium, 13-15 February 2006, Rio de Janeiro, Brazil (CN19).
4
Oliver, Adam J. & Mossialos, Elias (2004) “Equity of access to health care: outlining the foundations for
action” in Journal of Epidemiology and Community Health, 58 (8), pp 655-658.
5
The Tasmanian Hospital System: Reforms for the 21st Century (2004) p. 59.
5
How Does the Current Inequity of Access Affect Tasmanians?
The Richardson report identified a number of health issues facing all Australian
governments, including the ageing of the population, the increased cost of new
health technologies, the increasing cost of recruiting and retaining specialist staff,
and the need to maintain the highest standards of patient care.6 Tasmania is at a
disadvantage compared to other states and territories.7 Tasmanians have a
lower average life expectancy at birth than the national average. The cancer
death rate is the highest in the country. The diabetes and suicide death rates are
second only to the Northern Territory. A higher proportion of Tasmanians die
from heart disease and have chronic diseases such as asthma and arthritis than
the national average.8
Creating and Maintaining Equitable Access at the New RHH
The TCJPC has identified several groups that suffer distinct disadvantage under
the current Tasmanian healthcare system. Groups that urgently need greater
access to tertiary health care include:
-
Northern, regional and rural Tasmanians.
-
People with mental illnesses.
-
Pregnant Women and Children.
-
Families with low income.
-
Elderly persons.
-
Single people.
6
Note 3 at 5.
Note 3 at 5.
8
An Unfair State? Poverty, Disadvantage and Exclusion in Tasmania, TasCOSS report, October 2007.
7
6
This submission will look at the access issues particular to each of the groups
and identify any common themes.
Northern, regional and rural Tasmanians
The primary issues for Northern, regional and rural Tasmanians are as follows:
-
Transport;
-
Accommodation;
-
Effective collaboration of primary and tertiary services.
The new RHH must take into consideration systems of affordable transport to its
doors that are not primarily private (i.e. patient’s cars). Ineffective and expensive
modes of private transport are a barrier for rural individuals seeking health
services. The Richardson report stated ‘that the ambulance and patient transport
services may be readily upgraded to provide access to care, without loss of
quality or increased risk of death’.9 Inadequate and expensive transport puts
further strain on the ambulance system. Ambulances are often required by
patients in a non-emergency situation because they have no other means of
transportation. In addition to public transport considerations, the new RHH must
consider easy patient/traffic access, patient parking, disabled parking, a pick up
and dispatch area for patients.
9
Note 3 at 105.
7
Given the new RHH will be designated as the single tertiary care site in
Tasmania, it is of utmost importance that consideration be given to
accommodation services for Northern, regional and rural Tasmanians travelling
for treatment. This accommodation must be of an acceptable basic standard and
ideally be located in as close proximity to the new RHH as is practical. This
accommodation ought to be subsidised if not free to immediate family or primary
carers. If not subsidised then it should be affordable to individuals on income
support or pensions. In addition to the accommodation itself, there must be ready
access to services such as childcare, internet, phone and banking facilities. Also
the accommodation should be near retail services such dry cleaning,
newsagency/gift shop, chemist, coffee shop, florist, post office etc. In terms of
facilities for visitors on site, there should be after hours meal facilities, a safe area
for visiting children with safe outdoor play equipment, private area/family rooms
for discussions with families for all patient issues including bad news, common
recreational rooms for families and patients, a private area for patient/visitors to
use phone, an outside green area, sufficient security to ensure safety of staff,
visitors and patients. A holistic view to patient care recognises the importance of
family and friends to aid recovery. Creating an environment conducive to visitors
by providing accommodation and appropriate facilities is beneficial to patients.
Effective collaboration is needed between primary and tertiary health care
services. This is particularly pertinent in the case of rural health. A piecemeal
approach to service delivery leaves patients confused and agitated. Patients
should not have to travel unnecessarily to tertiary facilities for primary services.
There needs to be provision for tertiary services based at the RHH to have out-
8
reach clinics and diagnostic capacity in regional centres to limit the need to travel
to Hobart.
A review of how services are delivered at the RHH demonstrates a lack of
integration and partnering with associated service providers. The implications of
this are that strong inpatient-based models exist with an inability to divest
components of care to community-based services and other service providers
with any degree of success.
10
People with Mental Illnesses
The primary areas of concern for people with mental illnesses are:
-
The lack of access to trained Psychiatrists working in the public
sector.
-
The lack of access to collaborative mental health services.
-
Their over-representation in the prison population often due to lack
of access to appropriate care and support.
People with mental health problems are disproportionately likely to suffer
barriers to health care access. They are at a high risk of poverty due to
their lower participation in the workforce, the higher cost of their personal
needs, the consequences of their illness and the absence of essential
services including primary and respite care.11
10
Conrad Gargett Pty Ltd (2006) Royal Hobart Hospital Phase B Development Plan Study: Executive
Summary, September 2006, p.8.
11
ACOSS (2001) Breaching the Safety Net: The Harsh Impact of Social Security Penalties, at
http://www.acoss.org.au/upload/publications/papers/paper%20129%20Workforceage.pdf
9
People with mental health problems often experience co-morbidity. That
is, they have concurrent medical conditions as well as their mental
disorder. Mental illness and substance abuse frequently co-occur12. A
person with co-occurring diseases or disorders is likely to experience
more severe and chronic medical, social and emotional problems than if
they had a single disease or disorder. People with co-morbid conditions
are also more vulnerable to alcohol and drug relapses, and relapse of
mental health problems. Higher numbers of disorders are associated with
greater impairment, higher risk of suicidal behaviour and greater use of
health services.
The high levels of co-morbidity amongst people with mental illnesses
reinforces the need for greater collaboration between hospital and
community mental health services. Given the small number of acute care
beds, Tasmanians should not have to reach the point of serious illness
before they can access mental health services13. ‘Greater collaboration
between services’ is an often used phrase that needs manifest outcomes
if it is to be of any real meaning. The new RHH project needs to seriously
consider the hospital in the greater context of the Tasmanian community
services.
12
Commonwealth Department of Health and Aged Care (2001).
Anglicare Tasmania (2005) Response to Inquiry into the Provision of Mental Health Services in
Australia: The Senate Select Committee on Mental Health, p15.
13
10
The statistics on mental health in Tasmania are incomplete14 and do little to shed
light on the woeful fragmentation of the current system. Despite the goals set out
in the Tasmanian Mental Health Services Strategic Plan 2006-2011: Partners . . .
Towards Recovery report, Tasmania is far behind other states and territories in
its implementation of the National Mental Health Service Standards15. The
number of FTE staff in mental health services has decreased in number since
199316. Whilst the number of clinical psychiatrists and psychiatric registrars in
Tasmania is not insignificant, the majority of those doctors work in the private
sector. This leaves a small number of psychiatrists working in the public sector
with a majority of the caseloads in the state.
The current Psychiatric Department at the RHH, in conjunction with the
UTAS Department of Psychiatry, works well. However, it does so under
extremely stressful circumstances. The new RHH must maintain and
improve its Psychiatric Department in order to compete with the private
sector to attract a larger workforce.
Pregnant Women and Children
The first concern for gynaecological and obstetric services (GOS) at the current
RHH is infrastructure. Since the privatisation of the Queen Alexandria wing, the
RHH has been left with inadequate and indeed substandard space. The current
lack of beds has made it even more difficult for women to access elective surgery
in this area. Given the generally long waiting lists for other hospital services, this
14
CDHA (2007) National Mental Health Report 2007: Summary of Twelve Years of Reform in Australia’s
Mental Health Services under the National Mental Health Strategy1993-2005.
15
Note 11 at 150.
16
Note 11 at 136.
11
is particularly concerning. Adequate access also means that elective surgery
must be done in a time frame according to national norms. This means that there
needs to be sufficient bed capacity and professional capacity at RHH to do both
acute and elective work at the same time. It is also essential that the new RHH
provides high quality antenatal and post-birth follow-up services.
The second concern for GOS is the small number and composition of the clinical
staff. With the current poor facilities and the comparatively poor pay, the present
doctors at the RHH work under great stress.
Families with low income
Compared to the rest of the nation, Tasmania has the lowest average household
income, the lowest workforce participation rate, the lowest educational retention
rate for years 10-12 and a historically high unemployment rate17. These factors
all contribute to the current poor health status of Tasmanians and ‘contribute to
inequities in access to health services18.
The TCJPC wishes to ensure that poorer Tasmanians have access to an
excellent quality of health care. Our principles of upholding human dignity and
the common good mean that inability to access private health care should in no
way diminish the quality of care or access to it.
17
TasCOSS (2007) Submission to the Tasmanian DHHS on Clinical Services Plan Issues Paper
Australia Institute of Health and Welfare (2006) Australia’s Health: The Tenth Biennial Health Report of
the Australian Institute of Health and Welfare, Cat. No. AUS73, AIHW, Canberra, pp 156.
18
12
Transport is again an issue, particularly for low income families. The issues
raised above about equitable access for Northern, regional and rural Tasmanians
can be equally applied here.
Elderly persons and single people
These two groups also suffer distinct disadvantage. Elderly people generally live
on smaller incomes than their working counterparts and single people have
increased living expenses due to the increased cost per capita of living in a
single person home. Access to affordable transport is very important.
Conclusion: Recommendations
The TCJPC has identified equitable access as a primary consideration in the
planning of the new RHH. The Commission is particularly concerned that groups
that have been identified as suffering distinct disadvantage not be overlooked. In
order to do this, it is recommended that:
1. The Department of Health and Human Services (DHHS) identify how
other communities, with similar issues regarding
travel/accommodation to tertiary facilities, maximise access for
different groups.
2. The DHHS engage in further community consultation with the groups
discussed above to ensure any access plans will actually be
effective.
13
3. The DHHS works in collaboration with other government
departments (particularly the Department of Infrastructure, Energy
and Resources) to ensure an equitable transport system to the new
RHH is created.
4. Producing follow-up articles about the launch.The DHHS works in
collaboration with government and non-government services to
ensure affordable and ready accommodation facilities are available
for those needing to access the new RHH.
5. The DHHS ensures that the new RHH has sufficient facilities
associated with long term accommodation on its site for families of
patients and visitors.
6. The DHHS ensures minimal waiting list times irrespective of where
the patient resides.
7. The DHHS ensures that those needing to access the RHH are not
provided with poorer services than those in the private sector.
14