AMA(SA) SUBMISSION ON TRANSFORMING HEALTH Background

The AMA(SA) is glad to participate in the ‘Transforming Health’ discussion. Heath reform is an important and complex area in which consultation is vital. This current reform initiative faces some particular constraints and challenges. In this context we would also provide our ‘Key Priorities for Health’ document released earlier this year to indicate some key areas we have highlighted for system improvement. In relation to a key ‘transformative’ proposal previously put forward, the co-location of the Women’s and Children’s Hospital at the new Royal Adelaide Hospital (nRAH) site, the AMA(SA) continues to strongly support an independent but co-located Women’s and Children’s Hospital with the nRAH, as indicated in our previous submissions to government. We commend the doctors and other health care team members who contributed their time and ideas to the Transforming Health process and proposed Clinical Standards of Care. Any issues we raise regarding this document, process or standards in no way detracts from the important work that they have done towards an important objective.

The AMA(SA) agrees that we need to reform our health system, and look to how we can improve what we do in some areas. The AMA(SA) also agrees that any changes need to involve and have consultation with both the community and those delivering vital services. We can and should improve our health system. The question is how to achieve that. It needs to be the right reform: not shaping the reform to fit the financial cuts. Any changes need to be about improving the system to improve health outcomes for patients. Federal and state funding of health and the context of ‘Transforming Health’

When the federal government announced funding reductions in its 2014-2015 budget, and walked away from longer-term health funding agreements, the AMA(SA) was concerned at what this would mean for health services in this state. Already, we have been concerned that state budgets have repeatedly asked clinicians and those delivering vital services to effectively do ‘more with less’. Although state health funding grows each year, it has savings targets, yet demand keeps growing and some patients continue to miss out on the care they need when they need it. There are areas of inefficiency in the system but often these are related to not having the right services available (for example, enough acute mental health beds) or a disjunct between what happens in hospital and outside it (such as a lack of coordination or support for out-of-hospital care or rehabilitation). There is concern is that this huge investment in change is driven primarily by the need to find savings in the health system, rather than a desire to improve quality. Service improvements can deliver savings when there are areas of inefficiency: for example, avoiding ‘avoidable’ hospital admissions or emergency department visits can mean notable savings. That said, service and quality improvements do not necessarily deliver savings, and

sometimes ‘better’ is more expensive. Higher quality and higher accessibility can both cost more. Yet our community expects both high quality and reasonable timely access. Engaging the Community, Engaging Clinicians and the Transforming Health Process

It is appropriate to be clear and open with the community on the rationales for change, what the choices are, and what those choices will mean. What happens with our health services may ultimately be a decision of government, but decisions need to bring with them key stakeholders, and the two most crucial groups are those delivering services and the communities they serve. Consultation must be sound and genuine. We would prefer to see reduced bureaucracy than reduced clinical services, and we think patients would agree. We would also like to see more support for clinician leadership and clinical governance, and more engagement and consultation with the clinical workforce on system and service changes. Some of the suggested standards would require significant medical workforce practice changes that would need to be negotiated. Proposed Clinical Standards

We have received a significant level of feedback, including detailed comments regarding clinical standards, some of which we understand to have also been provided directly to the government. We have also received negative feedback on the consultation questionnaire as not being a good or sound mechanism for detailed feedback on complex and nuanced topics, and the process being limited. Many of the proposed clinical standards are in many areas quite specific and questions have been raised with us about a number of elements. We note the Transforming Health document flags that they will be subject to continued review, which is appropriate. However, before such standards are adopted we believe they need to be supported by relevant specialist medical colleges and other clinical leaders, in particular in specialty-specific areas. Generally speaking, the principles underlying the standards are sound, reasonable and understandable. However, medicine is highly complex and nuanced, with many exceptions and variable circumstances that need to be accounted for: the devil is most definitely in the detail. Broad acceptance is needed to achieve the desired outcomes and we believe more work will need to be done on some standards. Some may not be uniformly realistic, and some may have adverse unintended consequences. While we received some feedback that Clinical Standards are, for the main part, sensible and evidence-based, we also received questions on the evidence base for some, and whether they are realistic. We also received feedback that some standards are nebulous while others may be overly prescriptive, or whether they need to be part of this document if already part of care protocols in units. We also received feedback suggesting more would require service delivery changes than just those marked with an asterisk. We received some feedback that many of the standards outlined are obviously components of good care that are sometimes not met, but that it is unclear how these will be achieved more consistently with less funding, and some were described to us in feedback as idealistic but unrealistic. There was also feedback that the report did not provide a level of information to allow detailed analysis, but some generalisations were questioned. Feedback we received ranged from public hospital doctors, those working publicly and privately, and those outside the public system, for example GPs. Sufficient consultation and engagement is clearly vital.

We urge the government to take time to carefully consider the detail of the submissions and comments made and to provide further and ongoing avenues for feedback and consultation, and for further consultation and engagement to occur regarding any proposed service changes. In commenting on this document it is not clear what the outcomes will be in terms of actual services, and this is an area of clear interest and concern. Supporting the general intentions of this document does not equate to unconditional support of what decisions may come next. Clinicians stand ready to be part of positive change, but more work needs to be done to facilitate and support this. Our desire to engage does not end with this submission, and we anticipate our members will have further comments as time and the process proceeds. We need to find answers that strengthen and build on what we have. We will be judging any proposed changes against what they will mean for quality of care and access to services. Health is a highly complex and interrelated area. We must be very careful in making changes to understand what they will mean and we must be confident - and the community must be confident - in the results. What comes next and funding

The Transforming Health document represents high level visioning and many of the principles are uncontentious. The issues will be how it is operationalised, and this is the responsibility of SA Health. Change and improvement are to be supported but what is proposed requires reallocation of current resources, new practices and probably new investment, and herein will lie challenges. We received feedback from doctors concerned that significant changes are planned and that these may result in significant disruption of current services, and with concern that there may be insufficient beds, without the necessary support needed to evolve much more patient care from inpatient to day procedure and/or ambulatory and step-down/rehabilitation care. There is concern that sufficient resources will not be provided to support the whole system changes. As an example, we received feedback that new models of care for patients presenting to ED who could be safely discharged with an increased level of support, instead of being admitted, have been difficult to initiate because of the paucity of funding. In other words, if emergency admissions are to be decreased, much stronger early ambulatory care, including return to patients’ usual medical practitioner or appropriate ambulatory clinics must be available. It is certainly difficult to see how this can occur in current outpatient clinics, many of which have very long waiting lists for triage 2 and higher patients. This situation is very much compounded by the financial division of care between the state (inpatient) and federal and state (ambulatory). Federal state and the bigger picture

The federal-state relationship was raised as a gap in the document and it was highlighted that a key issue is that this hampers planning of complex systems. We received repeated feedback that review must consider this. We received feedback supporting the document’s principles of equity, access, effectiveness and best practice. The concept of improving delivery of health care is supported by all; what may not be so well supported is managing by “directive leadership” rather than by “facilitative leadership”. The AMA(SA) has commented often on the past about the need for sound consultation and engagement processes and the value of clinician leadership and clinical governance in health.

There is significant concern about potential service reductions. Members reinforced an early statement of the AMA that “the rationales for changes must be clear and transparent”. It was put that the question must be asked, of all proposed changes, “Will this reform improve quality of health care and outcomes, patient safety and equity?” Assumptions questioned

The thrust of improving the overall situation is laudable, but much of improvement depends upon accurately measuring outcomes of current care as a baseline to compare to any alterations. Detail in this regard is lacking. We received feedback that time in hospital, day surgery rates etc are important, but not the primary measures of care. Advances in technology may help all of these things, but have to be judged against the primary outcomes of treatment. “Transforming Health” mentions new technologies but the purported advantages of new technologies should be evaluated. We received some feedback questioning information in the document, and feedback that there is some (over)simplification. For example, thrombolysis as the core of stroke treatment was questioned. The perceived assumption that difference reflects badly was questioned. One commenter provided as an example the comment about high hysterectomy rates in SA, providing the feedback that this wrongly implies that hysterectomy is inappropriate surgery. The comment was made that differing procedure rates in some areas do not necessarily indicate inefficiency, but may reflect better practice. Another commentator said we may well have a higher ratio of emergency departments: population, but asked if this is comparing ‘apples with apples’, with reference to Adelaide’s ‘suburban sprawl’. The comment was made that the statistic of 5.4 emergency departments per 1m population, and comparison to other countries, is meaningless without discussing the relative sizes and capacities of these EDs. We received some feedback that waiting list data is not that helpful, and that that what is actually of greater importance is the work done, not what is waiting. The example was given that or instance, we do not make patients with bowel cancer wait, and that to do so would be inhumane.

Many of the graphs use means; we received some feedback raising concern that medians would be the more valid measure of data. We received feedback that the claims of 'higher' or 'high compared to' are not backed up by statistical analyses. It would be helpful to have more detailed information on these areas available as it is difficult to comment on some statements without having access to the data on which the statements were based. Some questions were raised with us about data sources, usage and interpretation. We received feedback that it is difficult to really interpret the various graphs of statistical information because each of the hospitals has a different profile of patients, staffing, and resources, and that comparisons between states should compare or taking into account other factors like distance, population density, use of private system, age profiles, etc. We received feedback querying some of the minimum numbers for procedures. The basis of these estimates needs to be transparent and, wherever possible evidence - rather than expert opinion-based. We received feedback that decisions should be based on the quality of outcomes both clinical and financial rather than just numbers of outcomes. We received feedback that the assumption is that higher volumes drives quality and effectiveness (efficiency) and that this is generally true but no magic bullet if resourcing is inadequate. We also received feedback that equity should be equity of outcome.

In relation to the concept that procedures which previously needed an open operation and days in hospital could now be done with keyhole surgery and day-stay, followed later in the document with equating a discharge from the emergency department with suitable-for-GP or urgent care centre. The feedback was raised with us that there is inconsistency in this - with the feedback that that patients who have spent all day in the ED getting investigations, consults and/or procedures are not there inappropriately even if they do go home afterwards. We received ED feedback that patients don’t often present inappropriately. We received some negative feedback about Michaela’s story on page 26: that patients should not be expected to know which hospital to choose for any of the things which might happen to them and their families. Gaps

Our feedback highlighted a range of gaps in the document, from the specific (such as ophthalmic services), to the more general (prevention, primary care and promotion) some of these are outlined below. While we understand the reasons for doing so (change what you can control, and the high costs in the public system) some questioned the rationale behind the document as limited by not taking a broader view. There was significant concern that training, research and rural health seem largely overlooked and that the implications that any changes would have on these areas may not have been sufficiently or appropriately considered. It was highlighted that sixteen percent of overnight stay patients in metropolitan hospitals live in regional South Australia. It was raised with us that there is no mention of Aboriginal people and while a functioning urban service underpins rural services, it is of concern that when dysfunction happens, rural misses out. There needs to be the right balance of services provided locally, with reference to evidence on what can be done safely locally, and access in metropolitan areas where needed. There also needs to be greater support of visiting medical specialists to country areas, and telehealth, which should be better supported in public hospitals, for example for outpatient services. In relation to the standards we received feedback that Standard 10 and a number of others would require a sub-clause on delivery of health care in remote and rural situations (eg Standard 17; and it was queried whether 267 would be feasible across urban areas also)

There was concern that, with its focus on clinical services, Transforming Health does not sufficiently consider the importance of training and researchLittle comment is made about the education and training of our next generation of doctorst was raised with us that the relationship with our universities and the conduct of basic research and collaboration with clinical disciplines are important measures. Research brings significant advances, but requires longterm commitment, funding and time. Universities, colleges and other entities involved in training, education and research should be involved and engaged in any reform process. It was raised that clinically directed research and development that is funded by government will greatly benefit the community as a whole.. We also received feedback about the value of creative thinking in the solving of complex problems which cross the boundaries of health care and other areas. In this complex and fast moving world we need more value attached to developing and harnessing innovation.

The importance of learning and education and research in the delivery of quality health care (including in urban tertiary hospitals) is well recognised internationally and supported by publication. The six quality principles do not include this area of quality practice and care. The NHMRC is deciding on a round of Advanced Health and Research Translation Centres

in recognition of this global evidence of the impact of research and teaching on quality of care. This crucial aspect of quality must not be overlooked. This is how advances in care delivery and technology use will occur. An additional 'principle' should be added to the document regarding good quality care, and that principle is sustainability; central to sustainability is teaching and training. A skilled workforce does not simply create itself; it must be nurtured and funded. Focussing specialty units in only some hospitals will require trainees to be properly rotated between sites to ensure they can experience required specialties as part of their training program. Role substitution also poses a serious threat to exposure of trainees to procedures; trainees already struggle to access a sufficient number of procedures in some vocational training pathways. Service changes can have significant and detrimental impacts on training capacity and hence workforce. In relation to the standards, Standard 34 indicates “Sufficient teaching, continuing education and research should be built in to all pathways; research and development activities should facilitate continuous improvement of services. Research and training programs should evolve to fit with new models of care.” However we received feedback of concern that there is no mention of quarantined time for teaching and training; nor of funding it. It was put to us that both of these should be within the standard. We received feedback about junior doctors negatively impacted by not attending training, yet not allowed time away from their duties in order to attend training, and budgets, earmarked for training, being otherwise used in the hospital. Prevention was raised as a significant issue to be addressed, and health promotion highlighted. It was suggested that prevention of obesity, diabetes, mental ill health, lung and heart disease through the common causes that we know exist, would mean significant health dollar savings. An absence of discussion on chronic disease was raised, although it is highlighted that ‘In South Australia in 2013-14 there were 36, 589 admissions to hospital for people with chronic conditions that could potentially have been avoided’. The AMA(SA) remains disappointed in the outcomes of the McCann review that saw the state government seek to move out of this space in favour of federal uptake. We received feedback that there is a population in the hospital system with chronic disease that would be better managed in primary care by GPs in the community who were supported to do it. We received feedback that the document has little about ambulatory care, subacute care and aged care, all external to public hospitals but critically important in determining inputs and outputs for the hospitals and length of stay.

A range of feedback we received made reference to the Generational Health Review and focus on primary care and hospital avoidance, and the subsequent SA Health Care Plan, and recent changes regarding Medicare Locals to become PHNs. We received feedback that what the Generational Health Review (GHR) intended to achieve has not materialised. We received feedback that tertiary care is of great concern regarding its cost burden but it is not where the changes need to be made and where the greatest cost savings can be made. We received feedback that primary care is where the greatest improvements to community health can be made and the greatest reduction in costs. Transforming Health’s focus on metropolitan hospitals, with little reference to general practice, is seen as a weakness. While the focus of this paper is metropolitan hospitals, city hospitals don’t work in silos separate from GPs. Improving connections with GPs would promote better productivity in hospitals. On page 29, it states that 59% of theatre cancellations are due to patient related causes – patient cancelled (maybe patient anxiety), unfit for surgery (maybe URTI) and failed to attend (maybe the elderly patient confused the

date). We received feedback that if patients were encouraged by hospitals to attend their GP as part of their pre-operative review, many of the issues could be sorted out, and so reducing the theatre cancellation rates in hospitals. In relation to proposed Standard 152, we received feedback that the importance of the 36 587 admissions for chronic disease, which "could be potentially avoided" (p16), requires close collaboration between the hospital system and GPs. Global health literature, particularly taking into account the impact of the social determinants of health and the impact of primary care on health, suggests that the actual impact on morbidity and mortality from the suggested changes to the SA public hospital sector is likely to be smaller than the bold implications in this document. One member commented that it appears to be more about a select few pathways of acute care than a holistic view. Making hospitals more cost effective and increasing the reliability of care in that context is important, but is only part of the picture. Hospitals may be where most of the expense is incurred, and governments should rightly attend to the cost-effectiveness of this care. We understand the rationale of this paper is to approach what is in the State Government’s direct control. But in terms of right care and right place, ignoring primary care makes this goal unachievable. We received feedback that the literature suggests that the links between primary and tertiary care are a more cost-effective place to start for reform. We received feedback that it is here that much duplication, mis-communication, delay, and non-evidence based decision making causes both increased patient distress and illness, and increased cost to government and individuals.

Private medicine in SA (specialists and GPs) make a very significant contribution to the health care system in SA. This should be recognised and acknowledged. This sector contributes substantially to ambulatory care and is in a sense a safety valve for the system. Private hospitals also play a significant role in both acute admissions and elective surgery services. We received member feedback that this should be recognized, with partnership with the private sector to ensure private services continue as a vital plank of future healthcare delivery for the public sector. Private care is an important part of the picture and understanding the services available in the private sector can assist with resource reallocation planning In addition to general practice and private practice, the omission of step-down facilities and -n-the-home services were considered important omissions when these are significant factors in reducing length of stay and avoidable hospital admissions. Bed block causes must be addressed, and these include issues such as access and transition to disability services and post-operative rehabilitation. Rehabilitation services is another important area, discussed in the document, but requires more support, engaging rehabilitation specialists, without detracting from existing resources and workforce expertise and training opportunities. Sufficient acute mental health beds and forensic beds has been another area highlighted by the AMA(SA) in its advocacy, and we hold that additional acute mental health beds are still required; also that there is a greater need for rehabilitation services to support lesser stays in an acute setting, and that rehabilitation should be provided in appropriate locations to where people live. In relation to Standard 52 “No patient should remain in a setting where they are not being actively managed.” It was suggested that this standard should have an asterisk applied, as large numbers of patients are kept in hospital “where they are not being actively managed” because of the absence of step-down facilities. If it is genuinely intended that this standard should be applied, then it will require massive restructuring of the SA health system, both public and private. The absence of step-down leads to lack of acute beds resulting in ED pressures.

Some members raised that this document examines clinical standards and clinical aspects but does not mention streamlining and increasing efficiency and cost-effectiveness of administration. We received feedback that improvement needs to take place in this area also. There is concern about unintended consequences and the comment that bureaucratic structures would also need to reform to match the core business. W We received feedback that transformation must address the administrative supports and financial reporting to align costs and benefits. Roles

It is a core belief of the AMA that "We must preserve the independence of the doctor/patient relationship." We received feedback concerned that these standards avoid any reference to the primacy and centrality in medicine and health of the doctor-patient relationship and that this seems to have been subsumed by profiling, principles, protocols, pathways, patient transfers and ‘practitioners’. We received feedback that the notion that "Clinical pathways should be developed by a multidisciplinary team and should be diagnosis or procedure specific rather than doctor specific" (Standard 22), may represent a diversion from the centrality of the doctor/patient relationship that would need to be carefully evaluated. One doctor/patient said to us: As a patient there are two key players in my care-in the community my GP and in hospital the doctor whose name appears on my bed card. I would hope that both of these have my best interests at heart and have assembled around them the infrastructure and teams to support and care for me. I value enormously the fact that my care is individualised, that the doctor treating me exercises to the full his/her professional independence and advocates for me to receive best care … The idea that this pathway of multidisciplinary care will be held together by a; ‘decision tree’ and a ‘chain of authority’ is highly concerning. We received feedback that a key principle of care in any health system is that it should allow its highly qualified and motivated doctors to exercise to the best of their ability their independent clinical skill and judgement and to individualise care in a truly patient centred way. Doctors and their relationship with their patients lie at the heart of health and its delivery. A system that diminishes or denigrates this misses a fundamental point and risks failure-for the individual patient and the system as a whole. Also in relation to the doctor/patient relationship, we received feedback in relation to Standard 6 (“Patients have a right to dignity and respect at all times. Patients should be able to express their wants and needs, or complain, without fear of retribution. Their privacy must be respected. There is zero tolerance of all forms of abuse” that abuse of health staff, including doctors, by patients and families, is more of an issue than staff abusing patients. There seems to be an emphasis on role substitution: nurse practitioners, extended care paramedics, but we received feedback raising concern that these roles keep the care of patients with the hospital and specialists rather than returning care to the patients’ GPs. The introduction of roles such as nurse practitioners or physician assistants can also have adverse training and exposure effects for junior doctors. However, a number of doctors would be assisted by more administrative support rather than having some duties undertaken by alternate health practitioners who do not have the same level of training. There are issues regarding the use of alternate health workers in space that has traditionally been the domain of medical practitioners, for example nurse practitioners, extended care paramedics and physician assistants. There are some benefits but also costs. We received feedback emphasising the importance of cooperation and collaboration between doctors and nurses leading to increased efficiency.

In relation to Standard 92 “Nurse practitioners should be utilised across the surgical system to improve efficiency” we received feedback questioning this this standard. It was suggested that it would be better to say: “If nurse practitioners can help efficiency, they should be utilized”. Practice

Many of the recommendations tend to suggest that more specialist services should be centralised and that patients should potentially travel further for services. This is appropriate for some areas, but there is concern this will be used to cut services at other hospital sites. We received some feedback that dedicated elective surgical centres "to improve access and quality" sound good in theory but would need on site HDU and general medical services unless they are only doing low risk surgery on healthy patients. One concern with centralising services generally – whether paediatrics, coronary care, neurosurgery or less urgent specialties – is that patients in peripheral hospitals could be treated as of lesser priority compared to newly arriving patients who present to the “right” hospital. We received feedback that centralised services must treat local and referred patients equitably on the basis of need but that doesn’t often happen. It isn’t inconvenience that bothers patients when local services close, it is actual access. We received feedback that there is clear justification for some highly specialised services being provided at fewer sites. However, we received feedback that basic services, such as general paediatric services, should surely be provided at every hospital which serves a region, e.g. ‘the southern suburbs’. Not to do so, would mean restricted access to these services, especially for those disadvantaged socioeconomically. Services are already integrated across sites. We received some feedback that no doubt this could be done more efficiently, as long as ‘better integration’ is not code for early discharge. However we did receive feedback that length of stay is clearly an area which needs to be addressed.

The document refers to “duplication of services” which is generally taken to mean provision of specialty and subspecialty units. From the perspective of the patient, a lot of the duplication is procedural – however we received some feedback that duplicating ED work is common, and that some clerical work is duplicated. Focussing specialty units in only some hospitals may improve outcomes for patients who are treated in those hospitals; however, it is critical to factor in the travel times and potential delay to treatment that may arise from such specialisation; inevitably there will be a subset of outer metropolitan / rural patients for whom earlier treatment in a facility with less throughput would on balance deliver better outcomes; additionally there is not sufficient space or capacity even in new facilities to take all patients who are currently served by outlier smaller specialty units. However, it was also raised with us that focussing specialty units in only some hospitals is contradictory to the opportunity listed on page 26 that there will be reduced patient transfers between different hospitals;

We received some feedback that our hospitals need improvements at night and on weekends/public holidays and improvements in the current on-call arrangements. We also received some feedback concerned that a number of recommendations appear to create siloes and walls, in terms of who can and can't do things, rather than promoting qualified and credentialed generalism and collaboration, with the feedback that this is an expensive way to provide care: “When one is trained in a specialty we are trained to deal with the whole spectrum of disease.” We received some feedback to suggest it would not be very satisfying, or attractive, to do just a limited aspect (e.g. lots of day surgery lists) day in and out. Such

training is fully realised when dealing with emergency calls at tertiary hospitals, where surgeons are rostered on 7 days per week, with a high level of commitment. It should be noted that work-life balance is an important principle for doctors as well as patients. A concerning issue from a consultant viewpoint is the view that consultants can supply a seven day service on a roster basis including the desire to stop private practice when on call for the public hospital (Standard 82). In relation to this standard, one member said “Beware of making it so difficult to conduct a mixed public-private practice that you alienate the best surgeons from the public sector.” We also received feedback that cancelling private practice commitments is an opportunity cost that would need to be reimbursed. The right balance needs to be struck that recognises the complexity and interdependence in the system. Concern was also raised that expectations of consultant and ancillary services commitment, such as interventional radiology services within 1 hour of request may not be workable in all circumstances, and the point made that a one hour timeframe would not be necessary in all circumstances but available when needed (Standard 78). A strong theme running throughout the Transforming Health document is that public metropolitan hospitals should be running 24/7 but this will mean at a cost. ‘Out of hours’ would be eliminated if a hospital goes 24/7 with no down- time. How does this reduce our beds and costs? In relation to Standard 71 “No surgery should be performed out-of-hours except in pre-defined emergency cases.” It was raised that “Out-of-hours” is undefined. In relation to Standard 79 “Clinical staff should adhere to safe working hours” the AMA has been a long advocate for and proponent of safe working hours but achieving them is difficult, and different guiding bodies have different view on what is required for safety and to balance training needs. Service demands, workforce issues and rostering in the hospital context are factors. It was also raised with us that this is not compatible with a large number of the other standards. In relation to standard Standard 54 “*Acute medical care needs the presence of a senior consultant 12-16 hours every day, who is readily accessibility to ensure early decision making. There should be clear protocols for their involvement, and the ability for 24 hour input in-person, over the phone or via telehealth.” We received some feedback that physical presence is potentially unnecessary, impracticable and expensive, and also that it may be outside the bounds of safe working hours. Standard 55 indicates “*All acute admissions should be seen by a consultant within 12 hours of initial assessment. High risk patients should not be discharged without having been seen by a consultant.” We received feedback that this may also mean consultants working far longer than safe hours unless there is an increase in medical staffing. We also received feedback that it would be impossible to apply when the consultant is trying to see several acute admissions at once. We received some feedback that the minimum time limit should be extended to 16 hours. In relation to Standard 60 Where a patient in AMU requires surgical input, a senior surgical review should occur within 4 hours” we received feedback questioning the achievability of this. In relation to Standard 76 “High risk patients must be discussed with the consultant surgeon within four hours if the management plan remains undefined and/or the patient is not responding as expected. These patients must have their operation carried out in a timely manner under the direct supervision of a consultant surgeon and consultant anaesthetist.”

We received feedback questioning if the second sentence achievable, or whether this an aspirational statement that may lead to problems. It was also asked why these two standards are rolled into one, with the view put that they are quite separate. Standard 78 indicates “*Interventional radiology should be available within one hour of request.” We received feedback questioning whether this is reasonable or achievable, or necessary for all types of interventional radiology. In relation to Standard 81 “*In specialties with a high emergency workload the surgical team should be free of elective commitments when covering emergency and consultants should not cover more than one site” there are 9 surgical specialities, not just general surgery. Some groups are small, so covering multiple sites is needed. This was echoed in other feedback which questioned whether there are sufficient resources or money, and its general achievability ie with the examples of specialties like neurosurgery or thoracic surgery or paediatric surgery – where there are very few practitioners in Adelaide - to not be covering more than one hospital? We received feedback that one very important aspect is mental health. Clearly within the hospital setting a far more efficient system needs to be implemented. Too many mentally ill people are in the emergency departments when this is not the best place for them, and are not receiving the help and care they need. We received feedback that any inroads to improve this situation (as for any other measure that helps to expedite patient flow through and treatment in the ED setting) should receive priority. We also received feedback that dedicated separate areas with sufficient trained staff are required for mental health patients. Inadequate acute mental health beds has long been an area of ongoing AMA(SA) advocacy. We also received feedback about how better engagement between EDs and general practice would be of value and could reduce ED-related investigations and subsequent inpatient activity, facilitating earlier discharge to GPs to manage subsequently. Also on the topic of ED, we received feedback with some concern that emergency medicine is not clearly discussed in the paper with concern that there may be a lack of understanding of what emergency physicians do, which is a vital and specialised role. It is implied in the documentation that trauma is best centralised. We received some feedback that the outcomes of trauma care, graded for severity, should be considered. This feedback agreed that the resuscitation and evaluation phase for traumatised patients needs to be streamlined and effective, but suggested in a state such as SA there should be at least 2 major trauma units with the relevant skills. Other standards feedback

One standard indicates that “All patients (and relevant support persons) should be actively engaged in developing care plans and end-of-life plans. Advance Care Directives should be in place.” (Standard 41). We received feedback from the intensive care field that advance care directives need to be the standard for all in aged care facilities. End of life planning is a core issue. We received in relation to Standard 14 and Standard 15 feedback that electronic systems while of significant value should not be given carte blanche; paper systems should not be excluded. We received feedback that the wording of Standard 228 needs to be corrected (“A paediatrician (GP or specialist) trained and assessed as competent in neonatal advanced life support should be available 24 hours a day and accessible within 30 minutes.” We received

feedback that it should read “a specialist paediatrician or GP assessed as competent …” (there are no GP paediatricians). The standard for a minimum of two anaesthetists for any stand-alone surgical site was questioned and we seek clarification (Standard 172). We are not sure why this was recommended and are not aware of evidence to support this. On this note, we believe it is important the professional colleges are engaged on standards relating to their area of expertise. In relation to Standard 262 “*Coronary interventional procedures, other than simple angiograms, should be performed at a facility with on-site surgical backup” We received concern from the field of cardiology that the restriction of angioplasty to hospitals with cardiac surgery is unnecessary. In relation to Standard 3 we received feedback that the statement “should include patient priorities” is meaningless, and the word ‘priority’ obscures the intent. It was asked: If there are fourteen patients trying to get treatment for only 10, does that involve selecting them according to priority? Or did we mean to say “the individual patient’s priorities” or “the individual patient’s preferences”? It was suggested it would be better to say: “should attempt to include individual patient’s preferences” because, in reality, some patients – and some families - expect unreasonable practices and behaviours. We received feedback of concern that Standard 8 is a positive motherhood statement, expressed in such unequivocal terms that it could later be mis-used. The remark was made that “Setting a perfect standard means that anyone can be accused of having failed” with the suggestion that there should be a qualifying statement inserted: e.g. “wherever possible” or “ideally”. A range of words were queried in various standards as unclear in meaning, or jargonistic. For example “target” in Standard 129; “Facilitated” in Standard 127; “escalation policies” in Standards 29 and 101; “Multidisciplinary criteria-led discharge” in Standard 38. We received feedback that Standard 161 “Where possible, patients should be triaged based on need for surgery or not. Those definitely not requiring surgery should be diverted to non-surgical services such as allied health led clinics” fails to recognise the role of surgeons in non-operative care. In relation to Standard 5. “Consumers have a right to information, data and reporting that is relevant to them. All information and test results should be shared with patients and they should be advised of all options for treatment and treatment setting” - We received some feedback that about this open data approach can harm the health service with UK and USA examples of problems in dealing with anxious enquiries about small abnormalities, with subsequently reporters of tests censoring themselves by omitting incidental findings from of the reports. There was also concern on impacts for practice and supervision of junior trainees diagnostic and management skills. In relation to Standard 19 we received positive feedback about the evidence-based movement in medicine but that what is missing is a standard on how practitioners and services should operate where evidence is simply unavailable. In relation to Standards 19 and 20 we received a feedback suggestion that we also need a Standard that encourages and defends conservatism; or decisions to revert to an old standard of management in appropriate contexts/parameters. It was suggested that multiple times new and apparently evidence-based ideas have been promulgated; and then partially or fully abandoned. It was put to us that sometimes a clinician is right in saying that “I know

that this procedure is recommended but I find that, in my hands, it is not as successful.” Some examples have been provided to support this feedback, which we are happy to provide. In relation to Standard 21 “Each presentation should follow a defined end-to-end patient pathway consistent across the state. Patients may require more than one pathway for multiple diagnoses, or if they belong to a group with identified special needs. Care should be delivered against this pathway, with protocols in place to ensure continuity” we received feedback that this standard does not make sense in any general medical unit where every patient has a unique combination of disease; nor in a large percentage of specialty patients who have multiple medical or psychiatric morbidities. Standard 22 and 27 “Clinical pathways should be developed by a multidisciplinary team and should be diagnosis or procedure specific rather than doctor specific. They should specify outcomes to be achieved, relevant timelines and should incorporate discharge-planning principles” And “Agreed pathways and protocols should be followed by all clinicians and unnecessary duplication should be avoided. All practitioners should engage in continuous professional development, including the best implementation of patient pathways.” We received feedback that these standards require an opposite standard that defends a surgeon against having to use a pathway “that does not work well in my hands.” Surgery is a craft that is extremely doctor-specific. It was also put to us that this would also stifle surgical and procedural innovation. The example was given to us of innovative behaviour now regarded as standard. It was also put to us that sometimes protocols and practices are based on very poor research. In relation to Standard 39 “Referrals should be pathway-based not directed to individual specialists, for example a patient with congestive cardiac failure should be referred to the congestive cardiac failure service.” We received feedback that this could deprive public sector patients of continuity of care. We received feedback that Standard 40 should incorporate the element that other members of the patient’s family be included in the process, and that this matter is insufficiently covered in the subsequent Standard 41. In relation to Standard 48 which indicates “There should be a clear decision tree and chain of authority to avoid disagreement around which admission clinic is appropriate.” We received some feedback that this standard may cause friction and that flexibility is a better approach. In relation to Standard 85 “Discharge planning should begin at time of admission; a discharge plan should be in place within 24 hours of admission.” We received feedback concerned that this standard may lead to meaningless aspirational discharge plans being put in place automatically and without purpose. We received the suggestion that “Discharge Planning should commence within the first 24 hours.” However we also received feedback that Standard 89 “Discharge planning for potentially long-stay patients should be proactively managed from admission” is a much better standard than Standard 85. In relation to Standard 88 “The WHO Surgical Safety checklist should be used for all procedures” we received feedback mentioning “Time Out” procedures and the question of who in the theatre should ensure that they are conducted.

In relation to Standard 93, Standard 95, Standard 96 “In mental health, community care is central to care.”; “Pathways should include structured phone follow up after acute care, where appropriate.” “There should be early referral to appropriate community or specialist teams for those patients” we received feedback that it is odd that this should be mentioned only for mental health and not for paediatrics, obstetrics, internal medicine, etc In relation to Standard 107 ”All acute mental patients admissions should be seen by a consultant psychiatrist within 24 hours of admission.” It was pointed out that the standard for consultant review in mental health is different from the standard for other specialties. Standard 173 “*Patients presenting with acute conditions requiring urgent surgery can be efficiently and effectively treated as day cases via a semi-elective pathway.” We received feedback that this is a rather concerning statement to be left unchallenged, with a request to see a list of types of surgery under this standard. In relation to Standard 178 “There should be state-wide agreement on the definition of “paediatric”, “adolescent” and “adult”, based on physiology” we received feedback that there are many ‘physiological boundaries’, depending on the body system that you have in mind. We received feedback that this statement should be altered to be more realistic and prevent tensions between services, and we received feedback that it would be better to have had a standard that insists on adolescent wards being available in all major hospitals. Standard 189 “*Children and adolescents should be kept separate from adult patients, ideally in dedicated facilities. Where they are co-located with adult services there should be clear separation from adult access.” We received feedback that adolescents need treatment areas separate from adult patients – but also separate from paediatric patients. In relation to Standard 53 “Newly admitted patients should be reviewed a minimum of three times in the first 24 hours by a clinician, for example a doctor or nurse practitioner, involved in their decision making, and at least once by a consultant” whether there is an evidence base for this was queried. It was suggested it creates an entirely new medico-legal environment. It was also raised that this would be overwhelmingly difficult in a rural hospital, and would require creation of a massive workforce. It was suggested this standard should have an asterisk. In relation to Standard 99 “There should be specific pathways integrating mental health care where non-mental health comorbidities exist. For example, when patients are admitted under acute medicine or surgery.” We received some positive feedback but also the feedback that it would have a big impact on restructuring, hence should have an asterisk. In relation to the above standards (175, 266, 268, 271) the basis for the numbers (33 procedures, 60 cases and 23 hours, 40 cases) were all questioned

Standard 175 “Where same day discharge is clinically appropriate but not practically feasible, patients should be pro-actively managed to be discharged within 23 hours. Standard 266 “Paediatric cardiac catheterisation should only be undertaken in centres with access to paediatric intensive care and paediatric anaesthesia. The paediatric cardiac catheterisation laboratory should perform a minimum of 60 cases a year to maintain proficiency.” Standard 268 “*Elective abdominal aortic aneurysm (AAA) repair should only be undertaken in hospitals where: there is a 24 hour on-site vascular on call roster every day covered by consultant vascular surgeons, there is a 24 hour critical care facility

every day, and there are a minimum of 33 AAA procedures per year.” Standard 271 *A bariatric service (surgeon with all support facilities) should perform at least 40 bariatric cases per year.

The evidence base for Standard 259 “Laboratories performing diagnostic angiography should have access to coronary care or intensive care facilities and their staff should be capable of inserting intra-aortic balloon pumps, and transvenous pacemakers” was questioned. However, Standard 123 “Acutely unwell elderly patients should see a geriatrician within 24 hours (in-person or via telehealth).” It was suggested the 24-hour standard for specialist review seems a more sensible standard than in other specialties. Door-to-needle time for strokes has been exactly defined (Standard 282). Yet it was raised with us that it has not been defined by standards in Cardiology. Standard 10 it was raised that patients would not know what the most effective area is. Standard 11 it was asked what systems will you put in place to measure the relevant clinical outcomes? For instance, in bowel cancer it is survival over 5 years. A number of standards were described to provide for things that are done already eg 13 and 14. Standard 19 it was commented that advances can be a matter of debate. Not all agree with meta-anlyses of data. Standard 25 it was raised that a problem can be that multiple copies then exist and one does not know which one is the latest. In relation to Standards 27 and 33 it was commented that the colleges drive this professional development process – why duplicate? In relation to standard 32 it was suggested this should be as determined by the professional colleges Standard 106 “*A comprehensive multidisciplinary psychiatry liaison service should be provided throughout the acute hospital.” We received positive feedback on the importance of having a funded consulation liaison service in public hospitals. In relation to Standard 34 it was suggested that research be defined, as some research is “blue sky” - it may vastly improve outcomes, it may not,or, it may in many years’ time. In relation to Standard 26 it was raised with us that technology should facilitate but not direct care. It was raised with us that there is potential conflict between Standards 21 and 3-4 between flowing pathways and patient directed care. It was raised with us that there is potential conflict between Standards 8 and 10 (right place of care versus as close to home of patient as possible). We received some feedback in disagreement with Standard 34 where teaching and research are placed within pathways rather than teaching and research being the drivers (for which there is good evidence) of improved pathways of care.

In relation to Standard 40 we received feedback about inadequate funding for clinicians to discuss advanced directives with patients and families. In relation to Standard 43 we received some feedback in relation to the statement “hospitals should be last resort” with the comment made that it would be preferable to state that hospitals should be used when it is the most appropriate site for patient care. We received feedback that Standards 54 and 79 conflict – consultant 12-16 hours per day + on call as against safe working hours. In relation to Standard 85 we received feedback comment that discharge planning should begin before or at time of admission. In relation to Standard 214 we received comment querying whether there is evidence to support this. In relation to Standard 281 we received feedback querying whether there is supporting evidence; thrombolysis of stroke is time critical; transportation to a single unit for state could lose valuable time. In relation to Standard 188 we received some feedback in support of this concept but with the feedback that SA Health has not been sufficiently supportive of plans for multi-disciplinary clinics for uncommon but complex conditions (both paediatric and adult). We understand that the Transforming Health discussion paper takes as its focus metropolitan public hospital rather than country areas but we received feedback concerned that a number of the recommendations are not appropriate for rural hospitals, and the language being used could result in many high quality services being shut down. Examples given were the requirement for a consultant anaesthetist for all paediatric anaesthetics (Standard 201), the stroke to needle times (Standards 281, 282), the major trauma requirement (Standard 275), acute mental health (Standard 106), and the general maternity (Standards 229, 238). We also received feedback querying feasibility of Standard 17 generally. Standards 10 and 16 were also queried for metropolitan settings. We seek clarification as to whether the standards are just intended to apply to urban LHNs or not. Recommendation 34 is the only one that is clear about the need for our public health system to engaged in research and teaching – we received feedback that this has to be a priority, be resourced, and appear in the KPIs of the CEOs. We received feedback that Standard 166 would require community resources. We received feedback that the paper included insufficient reference to workforce issues eg 24/7 full care, liaison psychiatry (Standard 104), and interventional radiology (Standard 78), failure to consider community resources in emphasising day surgery (Standard 166). The question was asked: who will determine which statewide centers are to be established (Standard 256). We received feedback that Standard 178: the definition of “paediatric”, “adolescent” and “adult” should also take into account the emotional and neurodevelopmental status of different age groups. The objective of this standard was also queried.

We received feedback that Standards 195 & 197 “every child…should be seen by a consultant paediatrician within the first 12 hours” are too prescriptive, and reduce clinician autonomy, without necessarily improving patient care and are likely to increase costs. This is

likely to result in attraction and retention issues. In addition, registrars need to learn to make some decisions as appropriate to their level, to ensure that the upcoming generation of consultant paediatricians are adequately trained. In relation to Standard 220 “all women should have access to midwifery care” we received feedback unsure what the intention of this , suggesting it read that “all women should have access to midwifery and medical care of a doctor”. Standard 221 we received feedback of significant concern that this could cause the closure of a number of smaller delivery suites, and threaten the viability of a large number of regional units. Standard 226 draws attention to the fact that there are no adult intensive care facilities at the Women’s and Children’s Hospital. This is a major issue and reinforces the AMA(SA)’s view that services at WCH needs to be moved to Royal Adelaide Hospital site (but with the WCH to retain independence). We received feedback concerned that Standard 238 also puts some of the regional institutions under strain. Standard 246 we received feedback concerned where there must be separate provision of staffing and resources to enable elective work to run independently of emergency work. We received feedback his situation does not exist in any private hospital in South Australia, with concern regarding private maternity services. Standard 249 we received feedback concerned this seems to prioritise discharge within 24 hours of birth rather than prioritise patient’s safety. Standard 254 was also queried. This submission represents a collection of views, feedback and concerns gathered by the AMA(SA) from its members. Points or issues raised do not necessarily reflect a formal position of the AMA(SA). However, we provide these comments and feedback for the due consideration of government as part of the Transforming Health consultation process. The AMA(SA) reserves the right to make further amendments or additional comments regarding this submission, subject to the approval of the AMA(SA) Council.