Will the federal government’s health reform work in fixing the problems on the ground?
Airdate: 
Tuesday, March 30, 2010 - 20:30
Channel: 
SBS

Nurses, patients and doctors on the inside talk about their experiences on the frontline of public hospitals.

We’ll be discussing bed shortages, staff shortages and waiting times in emergency departments.

Are regional and rural hospitals going to be winners or losers with the health reforms?

We’ll hear from patients who are waiting for elective surgery, and others who have recently had emergency surgery. What do they feel about their experiences in the hospital system?

Transcript

JENNY BROCKIE: Let's look at a woman who is sick of the talk and just wants medical treatment.

RHONDA HASTING’S STORY:

71-year-old Rhonda Hastings lives in Corio just outside Geelong. She is waiting for a double knee replacement.

RHONDA HASTINGS: I keep being told you've got to be patient. You know, you've got to be patient Rhondda. But I think that you walk a day in my shoes - sorry - and see how patient you can be. I can't do heaps of things. You know, all I want to be able to do is walk reasonably normal without the pain. During the day and even more so now of an evening in bed it's like just a throbbing tooth ache.

Nearly a year ago she finally got an appointment at her local hospital.

RHONDA HASTINGS: I went to the outpatients clinic at Geelong hospital. And was assessed there and they told me that the score that I got was 92 out of 100. Which put me in the semi - urgent category, I said to him 'Well what is urgent?" And he said well, you've basically got to be dying.

Last November she received a letter saying her waiting time for surgery was three months.

RHONDA HASTINGS: When I saw the second surgeon he told me there was a two to three year wait. How can they send you out a form that says your category surgery should be done in approximately 3 months? When they're telling you the waiting list is two to three years?

In the meantime, Rhonda is suffering.

RHONDA HASTINGS: The only place that I can get around without the rollator is inside my home. And I'm very slow. I'm not able to do my grocery shopping. I used to go up there, do the shopping, come home and sit down and cry with the pain.

Rhonda and her husband Bernie used to have private health insurance but dropped out when it became too expensive.

RHONDA HASTINGS: I sort of got a bit angry and said to my husband, you know, we should have hospital cover, I don’t care how much it costs you, I am going to ring up and find out how much it costs to have it privately done. And I was told $16,000 per knee. And that was just for the surgeon. Well, no ordinary people can afford to pay out that money then you've got your hospital costs on top of that and anesthetists all of that. So you'd have to be very well off to be able to do that.

And Rhonda doesn't think the proposed changes by the Federal Government will make a difference.

RHONDA HASTINGS: They're all promises. It's all what they're going to do and what they're not going to do and now I've got no faith in that. My daughter said to me, mum, in three years you'll be in a wheelchair. I don't want to end up in a wheel chair, I'm 71 - I'm not, you know, I shouldn't have to be waiting this long.

JENNY BROCKIE: Mark Kennedy, Rhonda attends your GP practice in Geelong, what is the actual wait for knee replacements like hers – is it three months or three years?

DR MARK KENNEDY, GP, GEELONG, VIC: Well, there's two elements I guess, the first part is that there's the delay between when a GP refers a patient to the outpatient department at a hospital and then once the patient actually gets seen at the hospital there's a wait before they get to surgery. We've certainly got a lot of patients that are waiting two years just to get seen in outpatients and then they are waiting on the hospital waiting list, so it can be up to three years for some surgery.

JENNY BROCKIE: Rhonda couldn't be with us tonight because of the pain she's in ironically, but, she is a category two, I have seen the letter her local area health service sent to her and it classifies category two as a condition causing minimal or no pain, dysfunction or disability. Do you think she's in minimal pain?

DR MARK KENNEDY: No, I think she's clearly in considerable pain, and it's obviously getting worse progressively as she's waiting for her surgery.

JENNY BROCKIE: So how does that happen? That people get categorized that way then?

DR MARK KENNEDY: I can't answer that question, because the categories that GPs write in their referrals are often not those that come back to the patients on the letters that the patients get. So they're often reclassified by the hospitals.

JENNY BROCKIE: How many patients like Rhonda would you have at your practice waiting for things like that?

DR MARK KENNEDY: For long periods of time?

JENNY BROCKIE: And in that kind of pain?

DR MARK KENNEDY: Several dozen. Several dozen patients.

JENNY BROCKIE: And is there any way you can speed up that process at the moment under the current system?

DR MARK KENNEDY: Yes, I think that you know, in terms of trying to get surgery as quickly as possible for our patients we've taken to referring them to a range of other hospitals in Melbourne and in the outer suburbs of Melbourne, and as far away as Warrnambool which is three hours away by road and they can often get done more quickly in those hospitals although there's a lot of transport and travel issues that create a lot of angst for the families obviously.

JENNY BROCKIE: How long do you wait if you're a private patient, just out of interest?

DR MARK KENNEDY: You know, for things like joint replacement, I think that should be possible within two to three months from referral to surgery.

JENNY BROCKIE: Pat, you're from Queensland, from the Sunshine Coast, and you were on a waiting list for a knee replacement at Noosa Hospital last year, tell us what happened.

PAT ISAACS, PATIENT, NAMBOUR HOSPITAL: Well, I've needed a knee replacement probably for some time. I finally got on to the waiting list at Noosa, which is a private hospital, but does a certain amount of public work. And the surgeon that had been reviewing me got me on to the waiting list there and within about a month I was shifted to another hospital. I just got a letter from Nambour hospital saying well, you're now coming to us, and you'll need to make an appointment to see somebody here and so I had to start all over again.

JENNY BROCKIE: Do you understand why that happened?

PAT ISAACS: No idea. The only thing I was told was that joint replacement funding was withdrawn from Noosa hospital, no-one has explained why, I had to actually ring up and find out why

JENNY BROCKIE: That was my next question, do you know at Nambour where you are and how long it is likely to take?

PAT ISAACS: No idea, all I know is they have over 1500 people on the waiting list at the moment, not all for joint replacements and I have no idea where I am.

JENNY BROCKIE: You don't know what number you are on the 1500?

PAT ISAACS: Sometime this year we hope is what they told me.

JENNY BROCKIE: Now, this is elective surgery.

PAT ISAACS: So they say.

JENNY BROCKIE: Why do you say that?


PAT ISAACS: Well, it's not something you just kind of choose to have done, it's something that needs to be done.

JENNY BROCKIE: How much pain are you in?

PAT ISAACS: Probably not as much as Rhonda, but I certainly have trouble sleeping at night. There are times when I can not move around without a walking stick, it's worse at sometimes than others.

JENNY BROCKIE: No private health insurance?

PAT ISAACS: I have no private health insurance. I used to have it and it got to the stage where I just couldn't afford it.

JENNY BROCKIE: Which is Rhonda's story as well of course.

PAT ISAACS: Which is Rhonda's story and it's not just paying for the health insurance, it's the gap - because very few health funds now actually pay for an entire knee replacement

JENNY BROCKIE: Have you thought about trying to get the operation yourself privately without the insurance?

PAT ISAACS: I've got no hope of that, my only income is an aged pension. Where am I supposed to find that money?

JENNY BROCKIE: How do you feel about the government's health reform idea, how did you feel when you heard about it?

PAT ISAACS: My initial reaction was yes that's probably a good idea. I guess one of my main reasons for saying that is you should be able to have access to first class care, whether you have money or not. That's my feeling. I think that health care is a right, not a privilege. But then when I think about it, yes it would be good if the Federal Government took it over, but it still needs to be managed at the local level somehow.

JENNY BROCKIE: Mike Butler, you are here representing the government on this, now, can you guarantee that these changes are actually going to ensure that waiting times for these people will be drastically cut? Can you guarantee that?

MARK BUTLER, PARLIAMENTARY SECRETARY FOR HEALTH: That is probably the primary focus of what the Federal Government has been doing over the last two year. When we came to government, there were literally thousands and thousands of cases like Rhonda's. About one in six people waiting for elective surgery and that just means surgery which doesn't need to be performed within 24 hours, so elective surgery is sometimes an unfortunate title. It's planned surgery that is nonetheless, important, necessary and must be done. About one in six people who needed elective surgery weren’t receiving it within the clinically recommended times and it's not just in elective surgery we had problems with waiting lists, about one in three people attending emergency departments were also not being seen within clinical recommended times.

JENNY BROCKIE: I get back to my question - can you guarantee that that is going to change under these proposals?

MARK BUTLER: The only way it's going to change is if we first of all deal with the continuing increase in pressure on our public hospitals and we think that the only way we can do that is for the Commonwealth government to take a greater role in the funding of those hospitals.

JENNY BROCKIE: Is that a yes, Mark, is that a yes, it will guarantee?

MARK BUTLER: Secondly, there are significant efficiencies we need to get out of our hospital system. Now what we did do when we came to government, was to put hundreds of millions into elective surgery, dedicated to trying to clear the waiting lists for elective surgery through 2008 and 2009. We delivered 62,000 additional procedures and are putting a lot of new equipment into about 125 new hospitals.

JENNY BROCKIE: I want a yes or a no to my question. Can you guarantee that you're going to drastically cut the waiting times through these changes that that will result in drastic reductions in waiting times for people like Rhoda and Pat?

MARK BUTLER: Well yes, that is exactly what we are going to do, if we can implement the hospital reform package we’ve talked about over the last few weeks and then make the sort of changes we need to make in our primary care system, to stop people going to hospital that perhaps don't need to be there, changes in our aged care system, and transitional beds out of aged care to allow people particularly older people to leave hospital when they can rather than when they find somewhere else to go, these are a range of things we need to do if we're going to reduce elective surgery waiting lists and reduce a range of other pressures that are on our public hospitals. There's not one silver bullet, there’s got to be a range of proposals that go forward and the Commonwealth needs to lead them.

JENNY BROCKIE: It is a big issue and we will get on to some of those things later, Gary, you were putting up your hand dying to say something?

PROFESSOR GARY GEELHOED, AMA PRESIDENT, WA: I was dying to say something. The problem in Australia is we don't have enough hospital beds - it’s as simple as that. The plan at the moment that the government is proposing puts no more hospital beds, no more funds into at all for at least three or four years - so nothing will change. Australia used to have close to five beds per thousand population – man, many years ago, it's now down to 2. 5, it’s much, much less than the average OEC, for instance, they have over 4. So we've cut something like 60 to 70 per cent of our beds since Medicare came in. At the same time, demand has gone up really dramatically.

The other thing is between 2001 and 2005 - bureaucrats in the health system went up 70 per cent. So there are not enough funds and the funds we are using we're not using properly either, so the plan at the moment as it is, won't change anything, we need more hospital beds the core business of hospitals is to look up the sick and injured when they turn up, get into a hospital bed and do the elective surgery, we don't have enough beds to do that, this plan at the moment, there may be more to come, but at the moment it won't do anything, just shuffling the chairs.

JENNY BROCKIE: Okay Angela, you're an emergency nurse in Launceston, are beds the main issue where you are?

ANGELA KNIGHT, NURSE, LAUNCESTON GENERAL HOSPITAL: For emergency nurses and medical staff, beds are huge, we're constantly bed blocked where I am and it's certainly not hierarchy that you know, not from them not trying to manage the situation, the demand is just higher, a huge elderly population, and it puts a big strain on the system for sure.

JENNY BROCKIE: What about members of the public, I'm interested in your experience, the bed issue, Deborah, what do you think?

DEBORAH WEBBER: I had an experience where my son was in an explosion, a gas explosion, and three boys were burnt, and the ambulance came quite soon, and it was very serious and we had to sit in the ambulance over 20 minutes because - and he was on the brink of dying, he was burnt everywhere and having spasms and breathing problems, and the ambulance wouldn't go anywhere, I kept saying, why can't we go? They said before there's no place to go. So there were three boys, and one went to the Concorde burn unit, and then finally, after 20 some minutes, the North Shore burn unit took the other two boys. And"¦ but the ambulance sat there, can you imagine an ambulance sitting there - your child is in that state and it's because there's no beds. That was three people.

JENNY BROCKIE: Yes Peter.

DR PETER MACNEIL, SURGEON, WAGGA WAGGA,NSW: Couple of quick points, Rhonda's plight is appalling, but there is no doubt that her joint surfaces have deteriorated markedly while she's been suffering, I'm a surgeon, I know that. So it makes any surgery more complex and difficult to achieve a good result, she might even need, for instance, bone grafting, which, but to go on further, one of the major costs of all this is the cost of the implant, of the artificial hip. Now, it depends on how many implants, hip implants the hospital is allocated and that's the reason why you can't get into your own hospital, in Noosa but it's okay to go to Nambou and also it is true that surgeons can't keep up their skills in their local hospital unless they go out to go and help out in the bigger hospitals and that's happening the whole time.


JENNY BROCKIE: We're looking at the state of our public hospitals and whether the government's proposed changes will make any difference. And Richard Harris, you're a vascular surgeon, in one word, how would you describe the hospital you work at - Hornsby hospital in Sydney?

DR RICHARD HARRIS, VASCULAR SURGEON, SYDNEY: Just to take a liberty, desperate, and neglected, buggered.

JENNY BROCKIE: Desperate, neglected, buggered. Three words you snuck them in, that's fine. We weren’t allowed to film inside Hornsby hospital so you filmed for us. Let's have a look.

THE HORNSBY HOSPITAL STORY:

DR RICHARD HARRIS: A nurse slipped over – hit her head and smashed her elbow in three places in the operating theatre. On the same night in the intensive care unit, I got a letter from a resident who says she slipped over in a huge puddle where water was coming through the light bulbs. The other day in theatres, one of the senior gastroenterologist had a door fell on him, and he suffered some minor injuries.

The biggest impact that I see is on the dignity. You've got 20 people looking at each other in an old Florence Nightingale ward, where there's cross infection issues, no dignity, no privacy. I do put myself on that journey from the old ward, you know, built 1971, which is very poorly designed, along this ridiculous corridor, looking up at mouldy ceilings and then you're hoping that you will go into a nice operating theatre, in fact you're not. I would be quite concerned if I was a patient in those circumstances. I don't want to see someone electrocuted or die to try to push the rebuild of this place.

JENNY BROCKIE: Richard, you had to be careful when you were filming that for privacy reasons, but 20 people in one ward. I mean...?

DR RICHARD HARRIS: This really is an incredibly old ward, built in 1933. The veranda is exposed to huge temperature changes, there's one bathroom for all the patients in those wards, there are two wards like that from 1933. Most modern wards, 1971, and it's been incredibly difficult to have the bureaucracy and then the government understand that this is a serious problem now.

JENNY BROCKIE: Why do you think you haven't been able to get action on it? I mean I know the NSW government recently set aside 1. 5 million to rebuild the roof at the hospital - is that going to help?

DR RICHARD HARRIS: This is 1. 5 million over a roof where the master plan says that this building needs to be bulldozed and the theatre complex moved to a more functional site on the campus so why they are putting $1. 5 million which would be great for planning the new hospital, into putting a roof over a dysfunctional building I don't understand.

JENNY BROCKIE: Michelle, three or four generations of your family have been in this hospital at various times, is that right?

MICHELLE DEWAR, PATIENT, HORNSBY HOSPITAL: That is right, yes.

JENNY BROCKIE: What is it like, is it as bad as Richard says?

MICHELLE DEWAR: It certainly is, yeah, it's not a pleasant place to be there as a patient. That's for sure.

JENNY BROCKIE: Why?

MICHELLE DEWAR: Just from what we've just seen in the footage there, at the moment, they've got a new emergency centre, which is great, you go in there and it's modern and clean. But as soon as you're admitted into hospital, you take that journey down those corridors and just like Richard said, you're looking up as these scary looking ceilings that have water damage.

JENNY BROCKIE: Brendan, you've been in the hospital, is that right, is it that bad?

BRENDAN DEWAR, PATIENT, HORNSBY HOSPITAL: I was talking to someone about it yesterday the way I described it was it's like a backpackers' hospital. It's not encouraging to get sick to go into that area, or that hospital.

JENNY BROCKIE: This isn't the only story we have heard like this, I know on our Your Say page, Mark Finn talks about one hospital in the eastern suburbs of Melbourne and he says "ambulances form lines at the back entrance and main public front entrance to deliver patients with beds scattered everywhere. There is rising damp in the toilets and showers and the lifts have paint chipped away from bed movement in the wards, it is sometimes hard to find a blood pressure unit that works and nurses have to take turns using the ones that work."

Now Richard, you've set up a Facebook page, haven’t you? What is that - in desperation to get something done?

DR RICHARD HARRIS: It's a good way of communicating to people who are interested in the whole story of Hornsby hospital that there really is a desperate situation and people have the opportunity of giving their opinion on that forum and people from the media and bureaucracy who don't seem to understand the problem can go and have a look at it.

JENNY BROCKIE: How much faith have you got that the man next to you is going to fix it?

DR RICHARD HARRIS: I met his boss the other day and he said he was going to come back to Hornsby later in the year, if he does a tour and if Mark does a tour, they will certainly want to be putting funds, because if you're going to have a National Standard and if the Commonwealth are going to take responsibility, then this is the first place to start.

JENNY BROCKIE: Still, my question is, how much faith do you have that things are going to change as a result of these...

DR RICHARD HARRIS: I'd hate to think it's just an accounting exercise. I don't want to be cynical about this. I hope that there is going to be progress and that this is a general attempt at taking responsibility.

JENNY BROCKIE: Mark?

MARK BUTLER: Well, there are 762 public hospitals in Australia and some of them are very brand new and wonderful places to work at and be treated at and some of them frankly need a lot of work. We have already put in the two years we've been in government put billions of dollars into hospital infrastructure which is not something the Commonwealth government usually does, we've only been able to touch 17 hospitals doing that, under the new plan, we are planning for the first time to become the dominant funder of capital, which is the hospital buildings and equipment and we recognise that that is a very big job for us to do in the future, to bring hospitals like Hornsby up to an acceptable standard for the 21st Century for the community around Hornsby, but we know that we're the only level of government that really has the means to do it.

JENNY BROCKIE: So how much extra money will there be for that then?

MARK BUTLER: Well, that really depends upon an assessment of all of the hospital stock that we have in the country. The states still have a very significant role to play in determining which hospitals need upgrading in some growing areas of the outer suburban areas of our capital cities new hospitals need to be built, not just existing ones upgraded so a significant job when you talk about 762 public hospitals to assess those, and we've been doing that over the couple of years that we have been in government, but again as I say, we can't do that sort of stuff over night.

JENNY BROCKIE: Peter McNeil you worked at a surgeon at Wagga Base hospital, for 33 years you are a consultant there now. The Prime Minister visited the hospital on the weekend, how are you feeling about the changes?

DR PETER MACNEIL: The changed he announced? There were none

JENNY BROCKIE: What do you mean?

DR PETER MACNEIL: Well, he, one of his pronouncements was, 'I see there was a promise of a new hospital in 2003, that's too long to wait, isn't it!’

JENNY BROCKIE: I mean the broader changes that have been announced by the Federal Government, not to your specific hospital.

DR PETER MACNEIL: You mean the long-term plan?

JENNY BROCKIE: How do you feel about the long-term plan?

DR PETER MACNEIL: It's a plan that will be activated in four years - 014. It's going to be then incrementally increased over the next five, ten X years. The world is going to be a different place and so is medical care by then. Any plan, I agree that it would be great to have a plan to put in more funds and maybe hang the dollars on the tree, as the tree grow, has grown, since you last did it.

MARK BUTLER: I'm not sure the 4 year time span came from, but if we get agreement at COAG in a few weeks time with the Premiers this plan is intended to start in 2011.

DR PETER MACNEIL: But it's incremental then?

MARK BUTLER: Well, we need to move to a national efficient price for example, because there's currently a 30% price differential between the most efficient state and least efficient state, we can't do that over night, but what we will do is take the dominant funding role from next year of the entire public hospital system, become the entire funder of primary care, so care outside of hospitals from next year, this is a very quick move to a fundamental realignment of a system that's tens of billions of dollars and tens of thousands of people.

JENNY BROCKIE: Gary?

PROFESSOR GARY GEELHOED: Well, just to be slightly cynical, I guess, you could say that this problem a lot of the problems in Australia at the moment in health have been caused by the Federal Government, they capped the number of doctors years ago, we don't have enough doctors now in this country, although that's being reversed. They used to match the states 50, 50, in funding hospitals it's now dropped below 40 per cent. That's largely the problem we have - we don't have enough beds in this country now because the Federal Government didn't pull its weight.

Now they say to the states, give us your GST, we will just reverse the 60/ 40 to 40/ 60, call it our money, say we're the main funder and we will fix everything up. I don't see it myself. It's not state money, it’s not Federal Government money, it's our money, it’s Australia's money and I think the money should go where it's needed to a system that has a close to services where you can, the people there can make the decisions about what goes into the hospital, what goes into preventative health and what goes into aged care, which we haven't touched on and what goes into primary care.

JENNY BROCKIE: I will get back to you Mark for a comment, but I want to talk about something other than buildings too for a moment. Matthew, the building certainly wasn't the problem when you got to hospital was it - at Blacktown Emergency department. Tell us what happened there last year?

MATTHEW HOLLANDS, PATIENT, BLACKTOWN HOSPITAL: That's the irony of it, probably for the facilities - that's quite a high standard, unfortunately not like Hornsby, but more in relation to the time waiting to be seen in the emergency department, for something that should have been simple procedure with appendix.

JENNY BROCKIE: It got very serious?

MATTHEW HOLLANDS: Went in on a Saturday complaining of symptoms after being referred to by my local GP, as I was advised that it was the correct way to go. Had a period of about three-and-a-half hours waiting on that day, did a few tests and was sent home on that day just with Panodine, nothing stronger and was told through a miscommunication on my part as I was told later on that some tests should have been done on the weekend, but they couldn't be because they did haven't the staff to do it and come back on a week day.

JENNY BROCKIE: So this was, presented to you as a staffing issue in this case?

MATTHEW HOLLANDS: That is correct.

JENNY BROCKIE: So what happened in the end?

MATTHEW HOLLANDS: Well, after a five hour wait on the Monday, longer than the original time, basically rushed through into surgery and was found to have acute gangrenous appendicitis with perforation. I had a 20cm scar and 23 staples later, three-and-a-half weeks off work, and something that really shouldn't have got to that stage at a fairly advanced hospital.

JENNY BROCKIE: We've got so much to get through, could do about five programs on this. Tilak, I want to move to the regions, to talk to you, because you're the only doctor at Coolah hospital in Western NSW, how many people does your hospital service at the moment?

DR TILAK DISSANAYAKE, COOLAH HOSPITAL, NSW: It's 19-bed hospital, with nine acute beds and ten aged care beds. Pretty much we serve approximately 125 to 150 outpatients a month.

JENNY BROCKIE: And for a population of what?

DR TILAK DISSANAYAKE: Population of the town itself, around 1,000 population, but in my practice, I have got over 2,000.

JENNY BROCKIE: How far away is the nearest big hospital?

DR TILAK DISSANAYAKE: Dubbo Base, one-and-a-half hours drive.

JENNY BROCKIE: What's your biggest need at the moment on a day-to-day basis, what do you need?

DR TILAK DISSANAYAKE: Coming from Melbourne working in places like Alfred hospital, from surgical training to come to a rural town, we don't have any x-ray facility, we have an x-ray facility but no-one there to operate it and the x-ray itself is a luxury commodity in the rural setting to decide to have that many patients coming through, pretty much day-to-day life, you go between hospital and the surgery to see patients as they come in. So it's a bit of a daunting experience to get basic things such as x-rays not available in a rural hospital.

JENNY BROCKIE: And lack of staff?


DR TILAK DISSANAYAKE: Very much so. The, I mean, myself pretty

JENNY BROCKIE: And how does that affect patients, how is it affecting patients?

DR TILAK DISSANAYAKE: Patients have to travel one-and-a-half hours by road and they're not quite sure whether you hit a kangaroo or a wombat on your way to get the x-ray or a simple blood test, it's not like taking blood, you send you to that place, I had to take all my blood and do most of the work, which is involved. It is a daunting experience, the amount of work, extremely high, and...

JENNY BROCKIE: Because you're it?

DR TILAK DISSANAYAKE: You're it.

JENNY BROCKIE: And you're it too Paul Mara. You're from Gundagai, in south west NSW, you and your wife are it I suppose, aren’t you, you are the only doctors there, same story - similar story?

DR PAUL MARA, RURAL DOCTORS ASSOC. OF AUSTRALIA: The only fully trained doctors there, we have doctors under supervision and I guess the issue with Tilak in terms of workforce - the way in which we structure our practice we will hopefully see in the future this issue being sorted out with the work force.

JENNY BROCKIE: I'm interested in the personal cost of this as well, I mean, what's the personal cost for you, working the way you do?

DR PAUL MARA: We don't like to personalise it that much, but over 27 years we've had one four week holiday together and one three week holiday together and at the moment my wife has a book which she writes and every time I go separately to her, she's tallying it up, it takes the drain on the children, it takes a drain on your personal life, and unlike a city GP, we provide the full gamut of services in our area, we are on call 24/7 basically, or supervising other doctors on that time, teach medical students. That's the sort of thing, it's incredibly demanding but it's incredibly challenging and exciting.

JENNY BROCKIE: What do you need?

DR PAUL MARA: We need more doctors. This is the whole issue about this hospital thing we have at the present time. We don't have the confidence in rural areas that this scheme is going to put one extra doctor into the rural setting and there are things that Mr Rudd can do now to support extra doctors coming to the bush.

JENNY BROCKIE: Like what?

DR PAUL MARA: Well, the Department of Health initiated a new classification scheme for incentives, that classification scheme put towns like Gundagai and Tumut and Tamoorah and Coottamundra in the same boat as doctors in Coffs Harbour, Cairns, Hobart and Wagga. There's no rational to that, and already we have registrars saying why do I want to work in Gundagai when I get the same incentives as working in Wagga.

JENNY BROCKIE: What tonight is all about is finding out how you on the ground are feeling about the federal proposals, what you're looking for and whether you think it is being met by this proposal?

DR PAUL MARA: I think we should be fixing the workforce first at the moment we don't have the policies in place to do so. We can't afford to wait for another four years - that is when the new money will start to come in, in this scheme. We can't afford to wait for the hospital stuff to occur. Our big concern is not only will Mr Rudd not meet the workforce requirements but there won't be the hospitals there because they will take the small country hospitals to use to patch up the other hospitals in their budget and that's a real concern of us.

JENNY BROCKIE: Mark?

MARK BUTLER: I'm not sure where this four year period comes from, the scheme would start next year, the Prime Minister has indicated he will make further announcements over the coming weeks and months.

JENNY BROCKIE: But the four years is that there's no new money until 2014...

MARK BUTLER: But the Prime Minister has indicated that there will be announcements in the coming weeks and months about extra money going to the hospitals.

JENNY BROCKIE: Here is your chance, you should tell us about it?

MARK BUTLER: I'm not the Prime Minister. But in terms of GP work force issues, I think rightly this is a huge problem that we've had that Gary mentioned, for a decade the number of GP training places was kept at 600, one of the more incomprehensible decisions over the last decade, we've already increased those training places by 35 per cent and only last week or the week before last the Prime Minister indicated that we would lift that from 600 up to 1200, this will create about 5, 500 additional GPs over ten years

DR PAUL MARA: Who will train these GPs?

MARK BUTLER: So the training arrangements are important we need to talk to the college, Chris Mitchell about that as well, but the last thing I will say is about the incentives, we inherited a rural incentive scheme to get more GPs into rural Australia that was fundamentally broken, based on very old outdated data and we used new data from the census that may not be perfect, I heard what the gentleman said about Gundagai verses Cairns but this opens up the incentives scheme to 500 new communities and about 2400 new doctors and for the first time this gentleman and his wife will be pleased to know, for the first time includes incentives to allow locum doctors to go in and allow rural GP’s to undertake some training, God forbid to have a holiday and do a range of things, all the pressures we feel in our health system in metropolitan Australia are accentuated in rural Australia, we know that, there's a particular challenge out in rural Australia.

DR PAUL MARA: That shows the level to which they don't understand rural. I mean, if we could find locums then we would use them, we are teaching at the moment, my wife and I supervising a PG - resident from a hospital, a registrar, two medical students and now been asked to accept two practice nurses to come on board. There's only so much we can take on.

JENNY BROCKIE: How do you solve that Paul?

DR PAUL MARA: I think you have to bury your head down and keep going and hope for the best at the end of the day.

JENNY BROCKIE: That's not very helpful.

DR PAUL MARA: I think this is the issue Jenny. We need to get more doctors into those rural areas, at the present time there is a growing differential in income between public sector doctors who are acting as our competition and rural doctors working out there, for us to equate our income with an emergency medicine specialist we would have to see 10,000 patient consultations a year each.


JENNY BROCKIE: The nurses have taken over Facebook, go the nurses. I will come to you Ged, they are writing on Facebook, they are saying they are over worked, exhausted, can't keep going in the system the way it is. Why is the public hospital system in such strife with nurses?

GED KEARNEY, AUSTRALIAN NURSING FEDERATION: Just because of what you said, I can imagine what they're saying on Facebook, I'm a nurse, I worked in the system for 20 years, I'm a mum, with four kids, live in the communities with people like Pat and Rhonda, and it's incredibly distressing for nurses to see their communities suffer like that and not be able to give the care they want. At the end of the day a nurse just wants to be able to deliver all the care that she possibly can for her patients and if they can't, if he or she can't do that, they leave the system. At any point we know there are 40,000 nurses registered who aren't working in the system.

JENNY BROCKIE: They're telling us on Facebook right now they're quitting the system.

GED KEARNEY: Can I say, you know, what we heard tonight is that the problem is huge, health reform is enormous and to say a simple solution, if I said to those nurses on Facebook, we will pop 100 beds in your hospital or another 30 cubicles in your ED, they would drop dead, they can't cope, it is not a simple solution to this problem to say let's add beds. It's one part of the problem but the reforms have to be big, we've been calling for big reforms and I think these are big reforms.

JENNY BROCKIE: Are you happy with the way the reforms are going?

GED KEARNEY: There's a lot of detail to be filled in and nurses are asking lots of questions but there are lots of things I do like about them, the local hospital networks, we understand, will give the nurses a voice, 55 per cent of the health workforce, nurses know what works, hopefully they will have a voice at the local level and say this is what we need to make sure people have operation

JENNY BROCKIE: Clare, you're a nurse in a major teaching hospital in Sydney, why do you think nurses are leaving?

CLARE WAITE, NURSE, ROYAL PRINCE ALFRED: Exactly that, work load issues, work load is out of control. You can't do your job and I think so many nurses are leaving because they're so dissatisfied. You leave work thinking what I didn't do today rather than what I have accomplished today.

JENNY BROCKIE: Is it about more than money, more than what you're paid?

CLARE WAITE: Money would be nice. But no, it's gotten to the point where people think you know, you could pay me another 10,000 dollars but I will still have an awful day at work, I will still be not professionally getting anywhere.

JENNY BROCKIE: Ged one of the government's election promises was to bring 7, 750 new nurses back into the system. Is that working?

GED KEARNEY: I don't think it's working for the reasons we just heard, nurses want to know they can manage work loads and they want to know that they can care for their patients. We need work load management systems, for example, in Victoria when they introduced nurse-patient ratios, we got thousands of nurses back into the system. Wasn’t necessarily extra pay, just a thought that well, I will have a manageable work load - I can do my job and feel satisfied.

JENNY BROCKIE: That means money, more resources?

GED KEARNEY: It means resources, money, again it's like adding beds, one part of the problem, I think work loads are the issue for nurses - definitely.

JENNY BROCKIE: And Mike Butler I will get you to respond to all of this, and how you deal with it, but why hasn't that worked? I mean, Ged says it hasn't worked, your election promise to get 7, 750 nurses back into the system, why hasn't it worked?

MARK BUTLER: I mean, you're right, we had a two-fold plan, one was to increase the number of university places for nurses and the other one was to bring the many thousands of nurses who have just dropped out of the workforce back into the workforce and try and create some incentive for them to do that. And Ged is right we haven’t got the numbers we hoped to get in any state really.

JENNY BROCKIE: Why have you failed?

MARK BUTLER: Well, we don't have a complete answer to that. But our very strong suspicions is the answers that have been given that the work load is very significant in public hospitals, it's not just about money, it's about quality of life.

JENNY BROCKIE: How do you address that as a Federal Government with this funding shift and everything else, how does this announcement actually address that issue?

MARK BUTLER: The funding announcement in and of itself is a foundation for bigger reform, and Ged made the point that there's a lot more information that needs to be given to the health workforce and consumers and the Prime Minister has indicated over the coming weeks and months there is a series of announcements, I talked about the workforce announcement for extra GP and specialist numbers a couple of week ago, we will make further announcements about nurse numbers and extra investments in public hospitals, particularly to deal with elective surgery and waiting times in emergency departments. But getting the funding architecture, getting who is responsible for dealing with the huge cost increases that are facing us in coming years, which if they're not addressed will make these problems even worse, that is an important foundation, then we need to roll out other announcements about how to deal with the very specific issues.

JENNY BROCKIE: Ged?

GED KEARNEY: I don't disagree with that, I'm looking forward to further announcements, because I think the whole system, we need to look at it wider than public hospitals, part of the reason we can't get bed access is there are older Australians in hospital beds waiting for nursing home beds so you have to fix the aged care system before you can actually fix the public system.

JENNY BROCKIE: When will we hear about that, because people are hungry for this information, they want to know, they want to know what's going to happen with all these things, when are we going to know?

MARK BUTLER: That's right. And the Prime Minister has indicated he's got more to say about aged care, more to say about primary care, because the bed supply issue is only part of the problem. We have, one of the highest hospital admissions rates in the world, in the OECD, we have twice as many people going to hospitals than Canada per head of population, 25% more than the UK, 25 per cent more than the US, significantly more than New Zealand, now, this is about the problems at the front end of the hospital system, where we don't have a co-ordinated primary care system that is dealing with people before they need to get to hospital, and we know that on any given day, about 20 per cent of older people in hospitals could be cared for in a sub-acute facility or in a community setting, so there is a lot we need to do to clear the bed block that one of the audience spoke about before so those beds can be freed up for people who need hospitals on those given day. So we have to get the funding right, work out how we deal with the increase in cost and then make some of those announcements like the Prime Minister said he would, about primary care, GP care and aged care at the back end.

JENNY BROCKIE: So Gary, why is WA holding out then, on this?

PROFESSOR GARY GEELHOED: That is what WA does of course, but... They're good at it! There's a lot of positive things about the plan. I've been highlighting how we got here and some ways how the Federal Government, both persuasions there of course are problems. The positive thing is that it says bureaucracy has gone mad, too remote, we need to put it back into something much more local and there will be imput from senior clinicians, doctors nurses, especially, that is very, very important but also we want to be able to do, have the, be able to manage these things locally, so for instance, aged care beds, you talk about Western Australia, we could free up so many acute care, very expensive tertiary beds immediately if in fact we had appropriate aged care beds but I think those decisions immediate to be made locally and I think what we're holding out for is that decisions can be made locally where we can balance things between remote care in the Kimberleys and aged care or primary care or hospitals, and do it locally the idea of having these things controlled from Canberra just doesn't wash.

JENNY BROCKIE: What are the patients making of this, we are hearing from the nurses and the doctors, Pat is sitting over there and listening to all this, what are you making of it?

PAT ISAACS: I don't really know at this stage, because I think the proposals are still in the early stages. One of the things that I have heard is proposed and in fact does happen from time to time and was happening in Noosa is that surgery be outsourced to private hospitals. I've got a bit of a problem with that, because if I believe that if that happens, then there's very little incentive to fix the public health system.

JENNY BROCKIE: Okay, can I get another comment the lady up the back had her hand up, yes?

WOMAN: Just in regards to the nursing, you were talking about and you also mentioned it's not just about numbers, I think it's not just about numbers in terms of the money going in, where you can afford more beds, you can pay more staff or have more staffing available, it's about the quality of the staff as well. I wanted to say really that I've been admitted into a country hospital on an emergency basis and as you mention, it's a full, the nurses provide the full service so the nurses there are of a quality, when they handled an entire situation without any doctor being present because it was very late at night and the doctor was on call because it was a weekend, it was fine because the nurses were very experienced, they were very, very well educated. I think you have a problem with that, I mean you're trying to rush in so many nurses now, because you want to fill a gap with staffing, but you're forgetting about the quality, that is really necessary.

JENNY BROCKIE: And David you want to have a say, I know you had a good experience in hospital didn’t you?

DAVID GILROY, PATIENT, FLINDERS MEDICAL CENTRE: I did, I can agree with that as well, because I was in emergency in the same place for almost two weeks with a cellular infection I brought back from Thailand and the care that I received was excellent, I didn't - yeah, the care that that I received was... exemplary and I have no complaints about the waiting room time or the doctors.

JENNY BROCKIE: When we called up for stories we got great stories from people with wonderful experiences of public hospitals which is a good thing, that the system is still managing to meet the needs of people, just despite these things.

DAVID GILROY: And I can also say over the two weeks that I was there, the majority of the care that I received was from the nursing staff, you know, I saw a doctor maybe you know, obviously for theatre you know, and for the occasional check-up every day or two, all the dressings, all of the primary care during the two weeks with nursing staff and you know, they were brilliant. So I think a lot of it comes down to the nurses, and we've got to look after the nurses.

JENNY BROCKIE: I wonder whether the government plans for these GP superclinics, whether people think that will ease some of the pressure that exists. Chris Mitchell?

DR CHRIS MITCHELL, ROYAL COLLEGE OF GP’S: First off, I think we do need to congratulate the government on their investment in terms of workforce, there are huge investments made in workforce and in terms of rural nursing, within the next three years about 50 per cent of rural nurses will retire from the system, so we absolutely have to make investments, GP supply has fallen by 2 per cent in the last 6 years so there are absolute issues with access. In terms of superclinics, well superclinics are not going to address public health outcomes because there are not enough to make a difference. We have to invest directly into primary care, community service and general practice to prevent illness and keep people out of hospital and direct access to move people on from hospital to aged care facilities, we need a strong community health care sector to do that properly.

DR PETER MACNEIL: I'd like to take a positive slant for a bit of a change, we haven't heard anything, one example, good, that’s the sort of thing that should happen. In Wagga Wagga we've got 75 specialists and a huge educational facility, both in the hospital, the medical school and the hospital, the Charles Sturt university trains a whole range of nurses, of nursing and other...

JENNY BROCKIE: What's the point you're making?

DR PETER MACNEIL: There are positives. All this is happening. Education and every 6 months Charles Sturt University graduates 600 nurses, doctors etc, but we're not alone, James Cook, Darwin.

JENNY BROCKIE: And we have, we were talking about this in the break, we have a lot of doctors coming through the system, but have not come through yet. That's part of the issue. We will have to wrap up, quickly. Gary, what do you want?

PROFESSOR GARY GEELHOED: What do we want? We want more beds. I appreciate all the problems there, and so many of the problems we said before, people working in emergency department, nurses on wards they say that is no not what I trained for this is not what I want. This is a matter of critical mass, if we can get enough beds in there so there's 85 per cent occupancy in hospitals nurses and doctors would have a pleasant working environment to work in, we would be able to have our elective surgery on time and we would be able to get our emergency patients in, at the same time we need control more locally and need to get rid of bureaucracy and get the doctors and nurses involved in making decisions locally.

JENNY BROCKIE: Mark, just a final comment from you, more beds, why no announcement about no beds?

MARK BUTLER: The Prime Minister said there would be announcements of investments in public hospitals - emergency departments shouldn't be running at over 100% occupancy, there is a great need there. But we can't think that is the only issue that needs addressing in the public hospitals, we need to deal with bed block, we need to deal with too many people in the existing beds, that could be dealt with elsewhere in and that requires a significant investment in primary care as Chris said and aged care ultimately, so this is a big job, we want the states to sign on to this, this isn't a plan we came up with lightly, it follows about two years of extensive review by the national health and hospitals reform commission and more than 100 formal consultations many of which run by the Prime Minister himself, this is a very well thought out deliberate plan we think is important for the health of the future.

JENNY BROCKIE: We will keep talking, we won't stop now. You can ask parliamentary secretary for health Mark Butler more questions about the government health proposal, you can also talk to Gary, Richard and Angela Knight. In the eastern states, click on the live chat. Give us enough time to get there. You can hear about the daily experience, doctors, nurses and patients inside the hospital system and tell us your story on Your Say.