Advanced Community Care

mmt Consultancy Services

Review of a proposal to establish a Multipurpose Service for the Central Highlands in the context of the Tasmanian Health Plan

MMT CONSULTANCY SERVICES PTY LTD in association with FRESBOUT CONSULTING INTERNATIONAL JULY 2008

The Evaluators, Marguerite Tohl and Dr Ron van Konkelenberg (assisted by Philip Hefferan) would like to acknowledge the valuable assistance provided by the Members of the Steering Committee and the Executive officer, Catherine Featherstone. We would also like to thank the people who provided information and the people who met with the Evaluators or were interviewed by telephone. In particular, we would like to acknowledge the time and the considerable input given to the Evaluators by the community in the Central Highlands, the staff of the Ouse District Hospital and other interested stakeholders.

CONTENTS

1 EXECUTIVE SUMMARY ...... 6 1.1 APPRAISAL OF MPS ...... 7 1.2 CONCLUSION...... 8 1.3 SUMMARY OF OTHER FINDINGS...... 13 1.4 SERVICE IMPROVEMENT...... 15 2 INTRODUCTION ...... 18 2.1 BACKGROUND ...... 18 2.2 REVIEW TASKS...... 18 2.3 EVALUATION STEERING COMMITTEE ...... 19 2.4 METHODOLOGY...... 19 3 POPULATION PROFILE...... 21 3.1 DEMOGRAPHICS ...... 21 3.2 GENERAL PRACTICE PATIENT POPULATION...... 23 4 HEALTH AND AGED CARE SERVICE NEED ...... 25 4.1 NEEDS IDENTIFIED BY THE COMMUNITY ...... 25 4.2 GP PATIENT NEED...... 26 4.3 NEEDS IDENTIFIED BY OTHER STAKEHOLDERS...... 27 4.4 COMMUNITY NEED IDENTIFIED BY THE DHHS...... 28 4.5 AGED CARE SERVICE NEED ...... 28 4.6 REHABILITATION SERVICES FOR OLDER PEOPLE...... 30 5 SUMMARY OF CURRENT SERVICES PROVIDED IN THE REGION...... 31 6 HOSPITAL SERVICES PROVIDED...... 32 6.1 OUSE DISTRICT HOSPITAL ...... 32 6.2 LONG TERM TREND - ADMISSIONS ...... 32 6.3 ALL HOSPITAL ADMISSIONS FOR CENTRAL HIGHLANDS RESIDENTS...... 34 6.4 24/7 ACCIDENT AND EMERGENCY SERVICE ...... 36 7 QUALITY AND SAFETY ...... 38 8 AMBULANCE SERVICES & GP ASSIST...... 39 8.1 AMBULANCE SERVICES...... 39 8.2 GP ASSIST ...... 40 9 AGED CARE SERVICES...... 42 9.1 RESIDENTIAL HIGH CARE PLACES IN ODH...... 42 9.2 COMMUNITY AGED CARE PACKAGES...... 43 9.3 HOME AND COMMUNITY CARE PROGRAM...... 44 9.4 RESIDENTIAL AGED CARE PLACES...... 46 10 OTHER SERVICES...... 48 10.1 GENERAL PRACTICE...... 48 10.2 REGIONAL HEALTH SERVICE ...... 49 10.3 CARER SUPPORT AND RESPITE ...... 49 10.4 TRANSPORT ...... 49 10.5 ATTRACTING FUNDING ...... 50 10.6 AVAILABLE FACILITIES...... 50 10.7 OTHER RESIDENTIAL AGED CARE FACILITIES ...... 50 11 CURRENT STAFFING ...... 52 12 COST OF HOSPITAL BEDS AND AGED CARE PLACES...... 55 13 OPPORTUNITY COSTS, SCALE AND PATIENT SAFETY ...... 56 13.1 OPPORTUNITY COST ...... 56 13.2 SCALE AND PATIENT SAFETY...... 56

MMT Consultancy Services July 08 - 3 - 14 OUTCOME OF COMMUNITY CONSULTATIONS...... 58 14.1 FIRST CONSULTATION ...... 58 14.2 SECOND CONSULTATION ...... 58 14.3 IMPACT IF HOSPITAL CLOSED...... 59 14.4 COMMUNITY PERCEPTION OF HOSPITAL...... 60 15 FINDINGS ...... 62 16 OPTIONS & VIABILITY OF A MULTIPURPOSE SERVICE ...... 68 16.1 OPTIONS IDENTIFIED...... 68 16.2 APPRAISAL OF THE MPS...... 68 17 SERVICE IMPROVEMENT ...... 72 17.1 SUMMARY OF SERVICE NEED ...... 73 17.2 SERVICE IMPROVEMENT...... 73 18 ATTACHMENT 1 – STAKEHOLDERS CONSULTED ...... 76 19 ATTACHMENT 2 – FIRST COMMUNITY CONSULTATION...... 78 20 ATTACHMENT 3 – CODES FOR TOWNS ...... 82 21 ATTACHMENT 4 – INFORMATION REVIEWED ...... 83 22 ATTACHMENT 5 – RHS ACTIVITY 2007...... 84

Figures Figure 1: Central Highlands Population...... 21 Figure 2: Numbers of people aged 75+ years...... 22 Figure 3: Number of Ouse GP patients by age ...... 23 Figure 4: Location of Ouse GP patients ...... 24 Figure 5: Number of Bothwell GP patients by age ...... 24 Figure 6: Types of chronic conditions of GP patients...... 27 Figure 7: Hospital admissions July 2003 to May 2008...... 33 Figure 8: Ambulance transports –volunteer and paramedic 2001/02 – 2005/06 ...... 39 Figure 9: Percentage of people who received HACC services in 2006/07 ...... 44 Figure 10: Difference between percentage of clients receiving services and percentage of the population aged 65+...... 45

Tables Table 1: Number of people by town...... 21 Table 2: Population Projections...... 22 Table 3: Other characteristics of the Central Highland region ...... 23 Table 4: Percentage of population grouped by population categories ...... 25 Table 5: Number of assessments by town over the last 3 financial years ...... 28 Table 6: Number of assessments undertaken per person ...... 29 Table 7: Recommendation of assessments ...... 29 Table 8: Types of services currently available in the region...... 31 Table 9: Occupancy rates of ODH hospital beds ...... 32 Table 10: No. of admissions and individuals ...... 32 Table 11: DRG - ODH patients 2006/07...... 32 Table 12: No. of admissions in the month X no. of months...... 33 Table 13: Hospital Separations by Patient Residence and Hospital ...... 35 Table 14: Diagnosis on admission for separations of Central Highlands Residents in ODH and other hospitals ...... 36 Table 15: Number of presentations by triage category ...... 36 Table 16: Adverse events 2005 through to 2008 ...... 38 Table 17: Number of ambulance carries volunteer and paramedic ...... 39 Table 18: Percentage occupancy of residential high care places ...... 42 Table 19: Aged care residents LOS and reason for discharge ...... 42 Table 20: LOS (in months) of low and high care residents 1999 – 2008 ...... 43 Table 21: Waiting list for CACPs ...... 43

MMT Consultancy Services July 08 - 4 - Table 22: Comparison of average hours per client for regions, the State and the bottom 10 SLAs ...... 45 Table 23:ODH Staff ...... 52 Table 24: Regional Health Services Staff...... 54 Table 25: Visiting DHHS Allied Health Staff ...... 54 Table 26: Average cost per bed ...... 55 Table 27: Opportunity cost ...... 56 Table 28: No. of people in the Central Highlands who attended the 1st consultations...... 58 Table 29: No. of people in the Central Highlands who attended the 2nd consultations...... 58 Table 30: Benefits and Risks of the MPS option ...... 69 Table 31: Application of Criteria to MPS option...... 70

Glossary A Multipurpose Service (MPS) model – An MPS model provides a flexible and integrated approach to health and aged care service delivery to small rural communities. The MPS usually comprises Australian Government funding for flexible aged care places, State funding for a range of health services and joint Australian/State funding for home and community care services.

The MPS model allows rural communities to pool Australian and State Government health and aged care funds within small rural communities and to apply these funds flexibly across all health and aged care programs according to community needs.

The MPS Program falls under the Aged Care Act 1997 and Aged Care Principles 1999. The MPS option creates a partnership between local community and the Australian and State governments. This provides an opportunity for the community to help set the priorities for local health care and to help identify any areas of exceptional need for care.

MMT Consultancy Services July 08 - 5 - 1 EXECUTIVE SUMMARY In April, 2008, the Australian and Tasmanian Governments funded an independent review of the future health and aged care needs of the Central Highlands Community.

The main task was to independently review the viability of a proposal to establish a Multipurpose Service (MPS) in the Central Highlands municipality of Tasmania.

The individual tasks of the brief were to:

Review the information collected by the Department of Health and Human Services (DHHS) and consider any other material, which may be from any source provided during the consultancy, including the consultations with the Central Highland community and other stakeholders;

Develop a report providing advice to the community, the Tasmanian and Australian Governments as to the viability of the proposed MPS; and

Provide advice as to alternative means by which health and aged care services at Ouse could be improved if it was considered that a MPS model in the Central Highlands municipality was not viable.

The Evaluators:

Met with the Steering Committee and agreed on methodology. Previewed information held by DHHS and other material. Drafted a notice advising of consultations to be held in the Central Highlands for distribution to the residents of the Central Highlands and other stakeholders. Drafted and placed advertisements in the local paper advising of the consultations and calling for written submissions. Conducted consultations with the local community in the week beginning 28th April 2008 in four locations (Ouse, Bothwell, Miena, Wayatinah) in the Central Highlands and with other stakeholders. Met with the Steering Committee to provide feedback. Received submissions. Compiled and analysed the submissions and additional data. Drafted a Consultation Booklet that contained information from the 1st round of consultations, findings to date and options for further discussion. Copies of the booklet were circulated to residents of the Central Highlands and other stakeholders. Conducted a second round of consultations in the week beginning 2nd June 2008 in Ellendale, Ouse and Bothwell (2 meetings) and another call for written responses. Conducted further data analysis Drafted a report for the Steering Committee’s comment. Met (via teleconference) with the Steering Committee on a number of occasions. Finalised the report. Presented the findings to the community and Governments at a meeting in Ouse on 17th July 2008.

MMT Consultancy Services July 08 - 6 - 1.1 APPRAISAL OF MPS In order to assess the viability of an MPS a range of criteria were developed and included in the Consultation Booklet. These were presented to the community at the second round of consultations for comment.

The following criteria were applied to the MPS proposal.

To what extent does the MPS:

Meet the priority needs identified by the community? Contribute to a robust health and aged care service that will continue well into the future? Enable a comprehensive and integrated range of services that will meet the changing health and aged care needs of the community? Ensure a quality service for the community? Enable the recruitment of a sustainable skilled workforce in the area to ensure safety of client care? Rely on the provision of a local medical service in the longer term? Maximise the resources and the facilities that are available in the region? Provide the opportunity to attract new funding to the region? Support the principles of the Tasmanian Health Plan.

An assessment of the criteria is outlined below.

CRITERIA MPS OPTION

Hospital and residential aged care beds will be able to be provided, subject to the high risks of being able to sustain the service. Meet the priority needs identified by the community. Additional funding will be required to meet other priority needs identified by the community.

Contribute to a robust health and aged care service Uncertainty of the continuation of the hospital that will continue well into the future. will continue because of workforce shortages.

Without additional funding the MPS will only Enable a comprehensive and integrated range of provide hospital beds, residential aged care services that will meet the changing health and aged places and only a small amount of community care needs of the community. services.

The risk of staff shortages for the hospital puts Ensure a quality service for the community. the quality of services for the inpatients and residents at risk.

Retaining the hospital will not guarantee a Enable the recruitment of a sustainable skilled sustainable skilled workforce. The distance workforce in the area to ensure safety of client care. from urban centres will place further pressure on attracting staff to the region.

The provision of hospital beds relies on a Rely on the provision of a local medical service in medical service in the longer term, which the longer term. cannot be guaranteed.

Maximise the resources and the facilities that are Resources would continue to be allocated to a available in the region. small number of people in the population. Yes, through the proposal to employ a Provide the opportunity to attract new funding to the Business Development Project Officer. region. Although there will be a low service base that the Project Officer will be starting from.

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Support the principles of the Tasmanian Health The MPS option does not meet the principles Plan. relating to sustainability, acceptable cost, The services provided by Tasmania’s primary health appropriateness, safety, or service integration. services should be: The option is also not focussed on health • accessible as close as possible to where promotion, illness prevention or early people live provided they can be provided intervention. safely, effectively and at an acceptable cost; • appropriate to the community’s needs; • client and family focused; • designed for sustainability; • integrated with the other elements of the health service system; • focused on health promotion, illness prevention and early intervention; and • delivered in a culturally appropriate manner.

Where services cannot be delivered safely, effectively and at an acceptable cost from within The MPS option is focussed on delivering local local communities, access to services should be hospital and residential aged care services. It facilitated through service coordination, the provision cannot be guaranteed that these will be able to of outreach services from an external base, the use be provided safely, effectively or at an of technology, transport assistance and other acceptable cost in the future. appropriate community support.

1.2 CONCLUSION The Evaluators acknowledge that there is a high level of support in the community and businesses to retain the Ouse District Hospital (ODH) and agree that the community needs access to hospital beds and residential aged care places.

However, it is the Evaluators’ view that establishing an MPS in the Central Highlands would not meet all of the objectives of an MPS, particularly in relation to quality of care and long term viability.

The Evaluators have determined that any option that includes the provision of beds or residential places locally, including a proposed MPS, is not safe in the long term, and therefore not a viable solution to meet the health and aged care needs of the community in the future.

The findings that support these views are outlined below.

QUALITY OF CARE AND CLIENT SAFETY Staffing Shortages Tasmania is experiencing considerable difficulties in recruiting and retaining nurses, particularly in rural and remote areas of the State. This problem is not unique to Tasmania and is being experienced internationally as well as in all other States and Territories of Australia.

The Directors of Nursing of the ODH have had extreme difficulties in maintaining a 24/7 nursing roster for some time reporting that the pressure has impacted negatively on their own health and wellbeing.

The existing staff have assisted to keep the ODH operating by increasing their hours of work, deferring recreation leave and at times agreeing to return from leave early to maintain the roster at the ODH. Staff of the hospital have

MMT Consultancy Services July 08 - 8 - accrued a significant level of annual and long service leave which is poor management practice and can no longer continue. Agency nurses have been contracted as well as nurses from other hospital sites to enable the hospital to continue, which impacts on the continuity and quality of care of patients and residents.

If the hospital remained open, many of the issues relating to managing the roster will certainly continue.

Staffing shortages are a direct threat to the delivery of safe in-patient and residential aged care. The risk of closing the hospital temporarily when staff are unavailable does not provide security or continuity of care for the residents or patients. The lack of a critical mass of qualified personnel in the ODH means staffing shortages will continue to occur, if not now, then in the medium term.

Regardless of the number of beds/places or if the model was an MPS, any effort to increase the beds or residential places to increase the critical mass would mean that more patients and residents will be put at risk. With the current staffing shortages it is highly unlikely that the required number of staff would be attracted to the ODH in the long term and thus ensure its viability.

The ODH competes for staff with all other hospitals in Tasmania and would continue to do so no matter what the bed/place numbers. The DHHS has had difficulties for years to attract suitable applicants for positions for the ODH as well as other hospitals. Solutions for attracting nurses are long term and have been implemented across Australia with limited success eg attracting overseas nurses with suitable qualifications. Even if the DHHS had the best recruitment procedures in place this would not guarantee that staffing would be attracted to the ODH in a sustainable way for the future.

24/7 Emergency Care Very few people are treated at the ODH for urgent medical issues and it is rare for an ambulance to take a patient to the ODH.

There are a range of risks in relying on the ODH as a 24/7 emergency service as follows:

The service relies on having access to registered nurses with a good understanding of primary and secondary assessment, sound emergency triage skills, good knowledge of how to use emergency equipment and good knowledge of the processes for accessing after hours medical and emergency response services. Whilst Regional Hospital nurses have these skills, very few rural hospital nurses have this experience and background. It is becoming increasingly difficult for the DHHS to recruit experienced agency nurses with a rural emergency background. The current staffing situation in Tasmania cannot ensure sufficient registered nurses in the ODH with adequate skills for 24/7 cover (and cover for sick leave, unplanned extended leave, annual leave and leave for continuing education). It is not safe for a registered nurse to be dealing with emergency conditions with only the support of an enrolled nurse or careworker on duty at the ODH, while at the same time being responsible for caring for inpatients and residents (such as, overseeing medications, intravenous fluids or assisting people with basic services, such as toileting).

MMT Consultancy Services July 08 - 9 - While the staff in the hospital provide reassurance and stabilisation for people who attend the emergency service, it is the Evaluators’ view that calling an ambulance immediately or GP Assist is a safer and more viable long term option.

It is acknowledged that ambulance response times need to be improved and a better arrangement needs to be developed for direct access by the community to GP Assist.

LACK OF DEMAND FOR ODH There are a small number of hospital beds in ODH. Occupancy rates and the number of admissions have been low for a considerable time and were even lower when a GP from New Norfolk had admitting rights to the ODH in 2006. In the last two years there has been an increase in admissions for same day procedures.

There is a lack of demand for the hospital beds in the ODH and the majority of people are going to other hospitals outside of the region. In 2006/07, 91.8% of hospital discharges were for people from the Central Highlands who went to a hospital outside of the ODH (ie 413 of 450 patients).

Efforts to increase occupancy and retain the hospital by managing more beds/places or offering additional services, such as post-acute care would rely on a sustainable and skilled workforce. With the current nursing shortages this cannot be guaranteed. Increasing beds/places would be a high risk strategy that would continue to threaten the viability of the service.

COST EFFECTIVENESS & OPPORTUNITY COST Inpatient facilities such as those provided at ODH are basically inefficient because of their size. Making comparisons with facilities of equal size is comparing degrees of in-efficiency. The real cost of providing inpatient services for a very small number of people in ODH is not providing community care and preventive services for a substantially larger number of other people in the community.

This economic assessment alone is sufficient to cause deep concern about the way the community’s scarce resources are being used. However, for the Evaluators this is not the key issue. The Evaluators ultimately came to their conclusion because of the unavoidable threat to patient and resident safety that is intrinsic to this type of facility.

Residential aged care places or hospitals are not basic primary health services. They are at the upper end of the aged care and health care system and are therefore carefully planned by the Australian and State Governments because they are high cost services.

Every Australian has a right to access high level aged care or hospital services when they need it, however these high cost services must be limited on a planning basis so that prevention, early intervention and home care services can be available locally for all.

LONG TERM VIABILITY NOT ASSURED If an MPS was to be established, the long term viability would continually be at risk and questioned by the funders of the MPS, (the Australian and Tasmanian Governments) and therefore the threat of the ODH closing would continue.

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This means that the level of uncertainty about the future of the ODH would continue for the community and that staff insecurity would also continue.

COMPARISON WITH OTHER MPS No direct comparison was made with other MPS’ as each MPS in Tasmania and across Australia is unique to its own area and all have a different profile. The size of the population, the types of services available, the number and type of staff, the geographic area covered and the distance to larger towns/cities all contributes to the sustainability of services and in particular the ability to attract staff.

In addition, the Evaluators considered the benefits identified by the community for an MPS and identified the risk as outlined below.

BENEFITS FROM COMMUNITY RISKS FROM EVALUATORS PERSPECTIVE PERSPECTIVE Establishing an MPS will secure the hospital With the current workforce issues and the small beds and aged care places in the future. number of beds/places and staff these services will not be guaranteed in the future. The uncertainty of beds/places in the region will continue (if not in 12 months then definitely in the medium term). The insecurity of employment in the hospital for staff will continue. The MPS will provide flexible bed use. The MPS will enable the beds/places to be used flexibly, but not for community services as the staff establishment must remain. More funding would be needed. There is a national and international trend to develop hospital avoidance models that will reduce the demand for hospital care. Day surgery and new technologies have already reduced the demand for hospital care. The focus on reducing demand will certainly continue in the future.

Increasing the use of the beds for step-down The occupancy rates of the hospital beds and the care and other short term care will increase number of admissions have been low for some occupancy and therefore the long term time. viability of the hospital. Efforts to retain the hospital by increasing beds or offering additional services, such as post-acute care and day surgery would rely on a sustainable and skilled workforce. With the current and future regional and state supply of nurses this supply cannot be guaranteed.

MMT Consultancy Services July 08 - 11 - community issues. It is more likely that the beds/places will be unstable in the future because of workforce shortages. Staff stability will be assured. Other MPS’ are experiencing workforce shortages. Any option including beds will mean that staff stability will not be assured. Staff would be fully utilised with a 16 bed A 16 bed MPS would mean additional capital MPS. costs and additional recurrent funding. Putting that aside, recruiting and retaining staff will still be an issue. An MPS is not just about beds it is about the provision of a range of services to best meet the needs of the community. This will require staff to work flexibly within and outside of a hospital setting. The majority of staff in the ODH have indicated that they do not want to work in the community and prefer to work in a hospital environment. This would create problems with allocating staff to deliver appropriate MPS services. Most services now exist There are significant gaps in health services for people living across the Central Highlands. For example: For older people there are gaps in low and high care packages, transition care, rehabilitation, home and community care services and home monitoring. There is very little support for carers, including respite. There are gaps in allied health services. There are gaps in transport options. There are gaps in services for children and young people. There are gaps in supporting new mothers and families. There are gaps in supporting people with chronic conditions. There are gaps in health promotion, preventative services and health assessments undertaken in the home. The hospital and medical facilities at Ouse It is recognised that hospitals in rural areas contribute to the emotional well being of the provide residents with a sense of security and community and this has value to the future community. health of all residents. However, under the MPS option the long term security of the hospital is not assured.

MMT Consultancy Services July 08 - 12 - 1.3 SUMMARY OF OTHER FINDINGS

Population profile In 2006, there were 2,242 people in the Central Highlands. The highest numbers of people were in the age range 50-59 years, followed by people aged 40-49 years. There were a higher number of children and young people than would normally be expected in a population profile in Australia.

The greatest concentration of people in the Central Highlands live in Bothwell followed by Ellendale, Hamilton, Gretna, Wayatinah, Ouse and Miena. The highest numbers of people aged 75 years and over live in Bothwell, followed by Ellendale and Wayatinah. More people live in the southern part of the Central Highlands.

The majority of the patients seen by the GPs in Ouse and Bothwell are adults.

Outcome of first community consultation More people attended the consultations in Ouse, compared to the other three locations, highlighting the concern about retaining the hospital. The first community consultations identified a range of population needs for health and aged care services.

Overall, there was strong support for retaining the ODH services (mainly in Ouse and Bothwell) and expanding hospital and aged care services. However, other health service needs were identified for children, families, young mothers and other members of the community. Transport issues were consistently raised as impacting on access to health services.

Other stakeholders The gaps identified by other stakeholders included, training and education for nurses, services for families, youth and children, palliative care, respite and better support for people with chronic disease. Other gaps included, immunisation for children and older people, mental health, increased Practice Nurse services and access to a “first aid post” for minor/initial treatment response.

GP patient service needs A high number of GP patients in the Central Highlands have hypertension, high cholesterol, insulin dependent diabetes and Type 2 diabetes.

Ambulance services The community raised concerns about the long response times for ambulance services from New Norfolk; however the number of ambulance carries by volunteer ambulances or ambulances coming into the region do not justify a full paramedic service in the Central Highlands. The issue of ambulance response times from New Norfolk needs to be addressed.

GP Access Improvements are needed to ensure direct access to GP Assist, an after hour medical advice service.

Entry to aged care services Older people in the Central Highlands are not receiving an ACAT assessment early enough, which delays entry to residential care.

MMT Consultancy Services July 08 - 13 - Due to the long length of stay of a number of residents in the ODH, the Evaluators consider that some residents in the ODH may have been assessed inappropriately for high level residential care. If transition care, rehabilitative services or alternative safe accommodation was available, such as an independent living unit, closer to facilities, this may have been a more appropriate option.

Aged care services There is not a clear understanding by the community that an Aged Care Assessment Team (ACAT) assessment provides a recommendation for both in- home and/or residential care.

Applying the Australian Government benchmark to the population aged 70 years and over for the Central Highlands population means that the community would require access to approximately 22 places across the Southern region of the state. This means that it is highly likely that some older people in the Central Highlands are accessing residential care outside of the region.

There is a shortage of Community Aged Care Packages (CACPs) in the Central Highlands and older people are receiving less Home and Community Care (HACC) services compared to other older Tasmanians.

General Practice The General Practitioner (GP) in Ouse is based in the ODH and the current facilities are very small.

If the facility did not have hospital or residential aged care beds it would not necessarily mean it would be more difficult to attract or retain a GP. The retention of GP services in rural areas is not contingent upon the existence of a rural hospital. There is no evidence that GPs are generally attracted to rural hospitals. Moreover, the GP Workforce and private GPs seeking to recruit to their practice have experienced doctors not accepting positions in rural communities because there was a rural hospital. Reasons include not wanting to be responsible for inpatient care (and the risks associated with that) and not wanting to provide a hospital on call service.

The Evaluators consider that Group Practices are more sustainable in the longer term to balance life/work and support contemporary practices. Moreover, with the support of Practice Nurses, particularly for chronic disease management and wound clinics, this would provide a positive environment for attracting staff.

Carers There are significant gaps in support and respite for carers across the Central Highlands and this needs to be addressed urgently to reduce carer stress.

Transport The State Government is currently examining the potential for significant improvements in transport options, including one telephone number to call to access a service. The Evaluators highly support this initiative as long the guidelines are flexible enough to incorporate the needs of the community.

Business development Centralink and Go Highlands are commended for the funding and services that they have attracted to the region. However, there is a need for a dedicated regional person to provide the leadership to build networks, create partnerships

MMT Consultancy Services July 08 - 14 - and attract increased funding for improved access to health and aged care services.

Current facilities There are good facilities in the region, such as the Ouse Golf Club premises and the Miena Community Hall that could be better utilised in the future. There are five units next to the ODH, which could be upgraded at a cost of up to $66,500 for use as independent living units for older people. 1.4 SERVICE IMPROVEMENT The Evaluators’ conclusion that an MPS would not be viable for the Central Highlands was based on the fact that an MPS must operate at least one residential aged care place. This means that the community cannot access other benefits of an MPS, such as the flexible use of funding to meet the changing needs of the community.

It is the Evaluators’ opinion that the MPS model needs to be reviewed. In an environment where many hospital sites are closing across Australia there is a need for a new flexible approach in the way services are delivered in rural and remote areas that does not rely on the provision of 24/7 care in a facility.

Services should be planned on a regional basis with established “hubs” for health service provision in more populated areas to provide a greater opportunity to attract and retain a skilled workforce. Planning must take into account where people usually travel for basic services, such as shopping and banking and address transport issues. Therefore planning should not necessarily be based on municipal boundaries.

Other health services in more local areas need to be “the spokes” that link into the “hub” to ensure access to the most appropriate health care for the local community. In some cases these could be “mini hubs” that provide co-ordinated services across small regions.

Outlined below are some identified areas to meet the health and aged care needs of the Central Highlands community in the future.

Mini Hub at Ouse Establish the ODH as a “mini hub” for the delivery of health and aged care services and most importantly the provision of information, with outreach “the spokes” to other areas (where it is most appropriate). The name of the service should be identified in consultation with the community and branding and good signage developed.

Facilities Improve the GP premises at the “mini hub”. Make better use of the Ouse Golf Club (eg day programs for older people) and Miena Community Hall (eg visiting health workers). Fit out the “mini hub” at Ouse more appropriately as a centre for administration, planning and service delivery, with areas for meetings and to undertake group programs.

Organisational structure Establish an organisational structure that reflects the new role of the service and incorporate the Regional Health Service to ensure joint planning and co- ordinated program delivery.

MMT Consultancy Services July 08 - 15 - Funding Bring together the funding from HACC and CACPs under the management of the “mini hub” and identify any other funding that could be managed in the region (not funding for visiting services). Contract a Business Development Project Officer with one-off funding for four years to attract more funding to the region. Overtime the aim should be for this position to become self-sustainable. Establish a system that identifies all of the health and aged care services available in the Central Highlands region to assist to identify gaps, improve planning and to promote services.

Transport Transport is a major issue for the community and access to health and aged care services must be improved as a priority.

Aged care services Apply to change the status of the 4 residential high care places to EACH packages (Extended Aged Care in the Home) to keep the funding in the region for people who require high level in-home care. Apply for additional CACPs and HACC funding. Upgrade the units next to the ODH for use by older people on a long term and temporary basis. Establish a day program at the Ouse Golf Club for social activities. Offer group programs for older people at the “mini hub” focussed on improving their health and well-being (eg preventing falls, managing chronic disease or mental health issues). Identify opportunities for the provision of short term transition and/or rehabilitation services that are either delivered within or outside the region. Establish an in-home palliative care program. Introduce new technology such as video telephones in older people’s homes to monitor their well-being and assist with medication management. Establish a home maintenance program. Increase opportunities for food delivery and outings that include healthy meals.

ACAT Assessment Better promote the role of the ACAT as early intervention could potentially delay the need for residential care.

Carers Increase the level of access to current services that support carers (of all ages) and/or develop new carer support programs including respite and carer support groups.

Nursing and careworkers Establish a Nursing Clinic that operates 8.00am to 6.00pm Monday to Friday from the “mini hub” in Ouse that provides one on one care (face to face or via a video telephone) as well as group health promotion and prevention in collaboration with the Regional Health Service. Assist the GPs in Ouse and Bothwell to access a Practice Nurse to increase the level of services in chronic disease management and home health assessments (through MBS payments). Increase access to community nursing and personal care, including Registered Nurses, Enrolled Nurses and careworkers across the region, with outreach posts, such as one in Bothwell with a visiting service to Miena and the surrounding areas.

MMT Consultancy Services July 08 - 16 - Identify opportunities to provide specialised nursing in the Nursing Clinic such as continence management (which is one of the triggers for residential care).

Chronic disease There needs to be an increased focus on the prevention and self- management of chronic disease, including increased diabetes education and support groups across the region.

Families, children and young people Develop programs that will support families, including young mothers. Increase support for young people.

Wellness Identify ways to increase access to services and activities that focus on wellness eg yoga and counselling.

Allied Health Identify ways to increase access to allied health services through partnerships, regional arrangements and improved transport.

Medical advice Establish a dedicated telephone line for the GP at Ouse so that when people ring the GP after hours the call goes directly to GP Assist and better promote the role of GP Assist in the community, Ensure the promotion of the proposed National Call Centre for the provision of medical advice, particularly for people living in rural communities and people traveling or working temporarily in rural areas.

Ambulance services The response times from New Norfolk need to be improved urgently. Increase training for the community, staff and nurses to improve emergency response services. Explore the need for a volunteer ambulance service at Ouse to compliment paramedic services.

Access to Emergency Care Develop an after-hours response program that includes GP Assist as the first point of contact through to an ambulance/helicopter response (depending on the level of urgency) and promote it throughout the Central Highlands.

The community identified a range of issues if the hospital and residential care services were not continued, that could not all be addressed in this report. These are outlined in Section 14.3.

The Australian and State Governments are strongly encouraged to work with the community and local providers to identify strategies to address the issues the community has identified in order to develop a robust health and aged care service for the future.

The community has put a lot of effort and energy into “saving the hospital” and the Evaluators observed that much of this commitment has arisen from fear of losing the hospital, particularly amongst the older population. To allay these fears all tiers of government need to work to rebuild the trust of the community to ensure that future service improvement is successful.

MMT Consultancy Services July 08 - 17 - 2 INTRODUCTION

2.1 BACKGROUND In May 2007, the Tasmanian Government released “Tasmania’s Health Plan”, which outlined the challenges facing the State in meeting the health needs of the community and described the future directions for the delivery of health care.

The Plan had a specific focus on a changed and expanded role for rural health centres. Two sites were specifically highlighted, one of which was Ouse.

The proposal to change the current health service in Ouse raised community concern across the Central Highlands. In response to these concerns the Australian and Tasmanian Governments agreed to fund an independent review of the best way to meet the future health and aged care needs of the Central Highlands Community.

The Australian Government, Department of Health and Ageing (DoHA) and the Tasmanian Government, Department of Health and Human Services (DHHS) engaged Marguerite Tohl, MMT Consultancy Services in association with Dr Ron van Konkelenberg, Fresbout Consulting International to conduct the review. MMT Consultancy Services and Fresbout Consulting International had undertaken similar projects involving community and other stakeholder consultations both in Tasmania and across Australia.

2.2 REVIEW TASKS The main task was to independently review the viability of a proposal to establish a Multipurpose Service (MPS) in the Central Highlands municipality of Tasmania.

The individual tasks of the brief were to:

Review the information collected by the DHHS through the development and implementation of the Primary Health Services Plan. Consider any other material, which may be from any source provided during the consultancy, including the consultations with the Central Highland community and other stakeholders;

Develop a report providing advice to the community, the Tasmanian and Australian Governments as to the viability of the proposed MPS; and

Provide advice as to alternative means by which health services at Ouse could be improved if it was considered that a MPS service model in the Central Highlands municipality was not viable.

The work was to be undertaken within the health planning principles of the Tasmanian Health Plan, as outlined below.

MMT Consultancy Services July 08 - 18 -

Primary Health Services Plan Health Planning Principles

To meet the objective of designing a primary health system that can better meet the changing needs of the Tasmanian community, the Primary Health Services Plan is based on the following principles:

1 The services provided by Tasmania’s primary health services should be:

• accessible as close as possible to where people live provided they can be provided safely, effectively and at an acceptable cost;

• appropriate to the community’s needs;

• client and family focused;

• designed for sustainability;

• integrated with the other elements of the health service system;

• focused on health promotion, illness prevention and early intervention; and

• delivered in a culturally appropriate manner.

2 Where services cannot be delivered safely, effectively and at an acceptable cost from within local communities, access to services should be facilitated through service coordination, the provision of outreach services from an external base, the use of technology, transport assistance and other appropriate community support.

2.3 EVALUATION STEERING COMMITTEE A Steering Committee was established to oversee the independent review. The Steering Committee included the following members:

Chair : A/State Manager, Tasmanian Office, DoHA: Anthony Speed

Membership: Deputy Secretary, Statewide Systems Development, DHHS: Mary Bent Assistant State Manager, Health Programs, DoHA: Catherine Brown Assistant State Manager, Aged Care, DoHA; Drew Beswick Director, Health Services Reform and Implementation, DHHS: Siobhan Harpur Central Highlands community members: Deirdre Flint Lyn Eyles and Michael Ball Executive Officer: Catherine Featherstone

2.4 METHODOLOGY The review was to comprise the following stages.

Stage 1: A call for written submissions. Stage 2: Consultation with the local community (no more than four locations in the Central Highlands municipality) and consultation with a number of other key stakeholders within Tasmania. Stage 3: Compilation and analysis of data.

MMT Consultancy Services July 08 - 19 - Stage 4: Feedback to the local community of findings from analysis with provision for discussion. Stage 5: Preparation of report. Stage 6: Presentation of report’s findings to the community and Governments.

The Consultants were required to meet with the Steering Committee at each subsequent stage of the project.

The following methodology was used to conduct the review.

METHODOLOGY Met with Steering Committee and agreed on methodology. Previewed the information held by DHHS and other material. Drafted information relating to the review for distribution to the residents of the Central Highlands and other stakeholders. Stage 1 Drafted and placed advertisements in the local papers with information relating to the review and calling for written submissions. Received submissions. Stage 2 Conducted consultations with the local community in four locations (Ouse, Bothwell, Miena, Wayatinah) in the Central Highlands and with other stakeholders with the main aim of identifying the health and aged care needs of the community. Met with the Steering Committee to provide feedback. Stage 3 Compiled and analysed data. Drafted a Consultation Booklet that contained summary findings from the 1st round of consultations, the analysis of data to date and the identification of options for further consultation. Copies of the booklet were circulated to residents of the Central Highlands and other stakeholders. Stage 4 A second round of consultations was held at Ellendale, Ouse and two in Bothwell. The main aim of the consultations was to receive feedback on the benefits and risks of each option. Another call for written responses was also made. Written responses received. Stage 5 Further data analysis was undertaken A draft report was prepared for the Steering Committee for comment. The report was finalised and presented to the community and Governments.

During the review a number of teleconferences were held with the Steering Committee. In addition, a sub-committee was established during the time that the booklet was being prepared so that this part of the process could be undertaken quickly.

The Steering Committee worked collaboratively to make certain that the process of the review was conducted fairly with opportunities for the community to be consulted. The importance of confidentiality was acknowledged by all members of the Steering Committee. The Evaluators did not disclose their findings to any member of the Steering Committee until the draft report was provided for comment.

MMT Consultancy Services July 08 - 20 - 3 POPULATION PROFILE The Central Highlands covers 8,010 sq km and covers 12% of the land mass of Tasmania. There are 2,2421 people living in the area and the population increases in the summer months in the north due to fishing and shack populations. Workers come into the area for up to months at a time.

3.1 DEMOGRAPHICS Figure 1 below shows the number of people by age living in the Central Highlands. Figure 1: Central Highlands Population

No. of people

450 400 350 300 250 200 150 100 50 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+

FINDING The highest number of people in the Central Highlands are in the age range 50- 59 years (n=389) followed by 40-49 years of age (n=349). There is a higher number of children and young people aged 0 to 19 than would normally be expected in a population profile.

Table 1 shows the available ABS Census data for towns in the Central Highlands. Table 1: Number of people by town No. of Town people Bothwell 556 Ellendale 476 Hamilton 300 Gretna 257 Wayatinah 169 Westerway 155 Ouse 133 Miena 105

FINDING The greatest concentration of people in the Central Highlands live in Bothwell followed there were more people living in Bothwell followed by Ellendale, Hamilton, Gretna, Wayatinah, Ouse and Miena. More people live in the southern part of the Central Highlands.

1 All population data is from the Australian Bureau of Statistics 2006 Census

MMT Consultancy Services July 08 - 21 - Figure 2 below shows the number of people in the region aged 75 years and older. Figure 2: Numbers of people aged 75+ years

No. of people in Central Highlands aged 75+

50 45 40 35 30 25 No. of people 75+ 20 15 10 5 0

y h e ll a a l e n w rw ti Ouse Miena milton a nda th Gretna a lle H E Bo Weste Way

FINDING The highest number of people aged 75 years and over live in Bothwell (n=43), followed by Ellendale (29) and Wayatinah (12).

Table 2 extrapolates the Central Highlands population to 2015; however it is very difficult to make projections for small populations. The figures in the Table extrapolate the rates of change experienced between 2001 and 2006. Extrapolations for males and females and for the three age groups have been re- scaled to balance with the Totals extrapolation. In these calculations the total population declines steadily. Most of this decline is in the male population with the female population remaining static. The 0-49 age group will decline significantly. However, ageing effects will result in an increase in the 50-69 age group and the 70+ age group remains approximately constant.

Table 2: Population Projections

2006-2008 Population Trends Extrapolated Age Groups 2008 2009 2010 2011 2012 2013 2014 2015 0-49 Male 671 655 639 623 608 593 579 565 0-49 Female 635 622 608 594 579 565 550 534 0-49 Total 1,307 1,277 1,247 1,217 1,187 1,158 1,128 1,099 50-69 Male 383 392 400 409 417 426 435 445 50-69 Female 342 354 366 377 389 400 412 423 50-69 Total 726 746 766 786 806 827 847 868 70+ Male 115 118 121 124 127 130 133 136 70+ Female 79 77 75 73 71 69 66 64 70+ Total 194 195 196 197 198 198 199 199 Total Male 1,165 1,158 1,150 1,142 1,134 1,127 1,119 1,112 Total Female 1,060 1,059 1,059 1,058 1,057 1,056 1,055 1,054 Total 2,226 2,217 2,208 2,200 2,191 2,183 2,174 2,166

Finding Statistical analysis indicates a likely small decline in the region’s population through to 2018.

MMT Consultancy Services July 08 - 22 - Table 3 shows other characteristics of the region compared to the State of Tasmania. A lower percentage of people are from a non-English speaking background or are unemployed and the median income for households and individuals is also less compared to the whole of Tasmania. The percentage of people in lone households is slightly higher compared to the rest of the State.

Table 3: Other characteristics of the Central Highland region

Characteristics of Central Tasmania the Area Highlands

% Indigenous 3.7% 3.5% % Non-English 6.7% 8.0% speaking at home Lone person 26.7% 25.9% household Median Individual $319 $398 Income Median Household $607 $801 Income

Unemployment Rate 6.2% 6.6%

3.2 GENERAL PRACTICE PATIENT POPULATION The GP in Ouse has 912 patients mainly from the south and south west of the Central Highlands and in towns outside of the southern boundary of the region. The number of consultations for the period October 2006 to April 2008 was approximately 8,890.

Figure 3 below shows the age of patients seen by the GP in Ouse. Figure 3: Number of Ouse GP patients by age

No. of patients x age

160

140

120

100

80 No. of patients

0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

FINDING The majority of the patients seen by the GP in Ouse are aged 50-59 years (mirroring the population profile) followed by people aged 60-69 years and 0-9 years.

MMT Consultancy Services July 08 - 23 - Figure 4 shows that the majority of GP patients live in Ouse, followed by Ellendale and Hamilton. Figure 4: Location of Ouse GP patients

Patients x location No. of patients

Glenorchy Brighton/Bridgewater New Norfolk Gretna Bushy Park Maydena Westerway Tyenna/ Nat Park Fentonbury Strickland Karanja Bronte/ Dee Lagoon Derwent Bridge Brady's Lake Tarraleah Wayatina Bothwell Osterley Ellendale Hamilton Ouse

0 50 100 150 200 250 300

The GP in Bothwell has 427 patients. Figure 5 shows that by far the largest numbers of patients are adults. 77 patients are aged 65 years and over.

The total number of consultations over the past 12 months was approximately 2,500. Figure 5: Number of Bothwell GP patients by age

160 140 120 100

80 60 40 20 0 0-4 5-14 15-24 25-54 55-64 65+

FINDING The GP in Bothwell has 427 patients. By far the largest numbers of patients are adults.

88% of patients live in Bothwell, with the remaining patients living in Hamilton, Hollow Tree, Pelham, Ouse, Waddamana, Arthurs Lake, Interlaken, Plenty, Gretna, Ellendale and Bronte Park.

MMT Consultancy Services July 08 - 24 - 4 HEALTH AND AGED CARE SERVICE NEED In order to consider health and aged care service need it is important to understand the nature of the community profile. In Table 4 below the population has been grouped into categories of children, young people, younger adults, older adults and older people to show the distribution of the population.

Table 4: Percentage of population grouped by population categories % of Age people Children 0-9 12.4% Young people 10-19 12.1% Younger adults 20-39 20.6% Older adults 40-69 46.2% Older people 70+ 8.7%

In the Central Highlands, the highest population category is older adults aged 40-69 years, followed by younger adults. This table shows that it is important that the needs of all of these population groups be considered for the future delivery of health and aged care services in the Central Highlands.

4.1 NEEDS IDENTIFIED BY THE COMMUNITY In the first round of consultations with the community the Evaluators asked the following questions.

What are the current key issues in the delivery of health and aged care services in the Central Highlands? What will be the key health and aged care needs of the community over the next 10 years?

The community consultations identified the importance of accessing aged care beds and accessing medical and emergency services, including ambulance retrieval. Allied health and transport were also key issues. In particular having access to a GP was seen as a high priority.

A comprehensive list of the identified needs is in Section 19 as an Attachment to this report.

The consultation in Ouse was focussed on the need to retain the beds in the Ouse District Hospital (ODH) and the residential high care places in the ODH, however there were a number of other gaps identified such as:

Services for older people - residential low care, independent living units, in- home support; Carers and older people living on their own – respite care, overnight, day centre and in-home; Transition care/ step down care in the ODH –for new mothers and others; Pharmacy; Basic first aid; Casualty - emergency care 24/7; More hospital beds; Post acute care in the ODH; A full-time GP services and 24/7 medical coverage at ODH; Palliative care – in hospital and in-home;

MMT Consultancy Services July 08 - 25 - Independent living units for older people near to hospital; Transport; Allied health – physiotherapy, dental, optical, audiology; In home support for people with chronic conditions and self managed groups; Personal care, home maintenance, meals on wheels; Support – Parenting, carers, youth, domestic violence; Access to information re equipment; Volunteerism; Increased 0-5 child and family health; Support Network – single mothers; Immunisation; Mental health services; Health education in schools; and Preventative services.

The participants at Wayatinah identified the need for aged care beds, respite care, in-home support, pharmacy, services for children, youth and young mothers and health education perhaps provided by “roving” clinics.

The consultations in Bothwell identified the need for aged care beds, in home support, independent living units for the elderly, mobile x-ray, access to information and promotion of healthy lifestyles, carer support and preventative services. In addition, the community highlighted the issues around cost of travel, isolation, condition of roads and the difficulty of travel at times due to weather conditions (these issues were also raised in discussions with other communities).

The participants at the Miena consultation identified the need for visiting community nursing, increased training for the volunteer ambulance officers and preventative/ post-incident care (eg physiotherapy, yoga, counselling, lifestyle support).

They highlighted the increase in the population during the summer months, the poor mobile/internet coverage and questioned if they needed the hospital “just because it is there”. Furthermore they stated that “Ouse is not central’ and suggested that services such as community nursing could be provided from Deloraine as it is closer.

A suggestion was to use Ouse as a medical hub overseeing services delivered to outlying towns such as Miena. In addition, the community suggested they could establish a local Self-Help Register eg of people with a good phone or people with medical experience who are available locally for support.

FINDING The first community consultations identified a wide range of population need for health and aged care services. More people attended the consultations in Ouse, compared to other areas. There was strong support for retaining the ODH and expanding hospital and aged care services. However, the consultations also identified health service needs for children, families, young mothers, people with chronic disease and other members of the community which are currently not met.

4.2 GP PATIENT NEED The type of chronic conditions of patients seen by the GP in Ouse is outlined in Figure 6. The GP in Bothwell confirmed that the patient profile of conditions was very similar to those identified by the GP in Ouse, except there are a higher proportion of people with diabetes.

MMT Consultancy Services July 08 - 26 -

FINDING A high number of GP patients in the Central Highlands have preventable conditions such as hypertension (high blood pressure), which is a high risk factor for stroke, high cholesterol, which is also a high risk factor for stroke as well as heart disease, Type 2 diabetes and chronic obstructive airways disease. Figure 6: Types of chronic conditions of GP patients

Types of chronic conditions No. of patients

250

200

150

100

t e es D n is is n t A o trol nia sulin re rhrit rthrit Gou ssio in iabe CO Stroke rt Bipolar ph l Failur Asthma rtensi ementia A pre 2 d e rt Disease D tes - e steoa De ena Hyp igh choles R be yp O Schizo ia T H D h. Hea nic sc ro I Rheumatoid Arthritis h C

4.3 NEEDS IDENTIFIED BY OTHER STAKEHOLDERS The Consultants also held meetings and telephone interviews during the week of the 28th April with approximately 45 people. The interviewees included State and Australian Government officers, representatives of businesses, other health and aged care providers, representatives of community organisations, staff of the ODH, the local GPs, various Associations, Police, fire and ambulance services, Unions, other representative bodies and community members.

A list of the stakeholders that the Consultants met or held telephone meetings with is in Section 18 as an Attachment to this report.

The main purpose of the interviews/meetings was to gain further information and to provide an opportunity for people to express their views about the needs of the community. A considerable amount of information was gathered by the Evaluators. The views of stakeholders varied significantly given that it was such a diverse group. Some people supported the need to retain the sub-acute and residential care beds in the region while other people (not exclusively Government officers) were extremely concerned about the long term sustainability and risks of continuing to operate the hospital.

FINDING The gaps identified by stakeholders included:

Training and education for nurses; Services for families, youth and children; In hospital – palliative care, respite;

MMT Consultancy Services July 08 - 27 - Better supporting people with chronic disease and an increased emphasis on self management; Transport; Immunisation for children and older people; Mental health; Increased Practice Nurses services, particularly for people with chronic conditions; Access to a first aid post.

4.4 COMMUNITY NEED IDENTIFIED BY THE DHHS The gaps identified by the Department of Health and Human Services for the Central Highlands include:

Greater access to home-based services such as post-acute care and specialised community nursing; Greater capacity to treat diabetes and other chronic diseases at the primary health level; More emphasis on health promotion; Greater capacity to work with young people through collaborative partnerships, to adopt healthy lifestyles; Increased access to mental health and alcohol and drug programs, and An expansion of the approaches to self-management of chronic disease. 4.5 AGED CARE SERVICE NEED There is an Aged Care Assessment Team (ACAT) in the south that provides an assessment of the needs of people who are becoming frail or their health needs have changed.

The Team makes a recommendation as to whether the older person requires low or high level care in the home or in a residential setting. An assessment is required before people can access any Australian Government funded residential places or aged care packages.

Data was collected for the period 1 July 2005 through to 10 April 2008 (approximately 34 months). Over that period 60 assessments were undertaken for 36 people. Table 5 shows that most of the assessments were for people living in Bothwell, followed by Ouse, Ellendale, Gretna, Hamilton and Hollow Tree. Table 5: Number of assessments by town over the last 3 financial years No. of Town assessments BOTHWELL 16 OUSE 12 ELLENDALE 9 GRETNA 5 HAMILTON 5 HOLLOW TREE 5 APSLEY 3 MIENA 2 BRONTE PARK 1 FENTONBURY 1 WAYATINAH 1 TOTAL 60

MMT Consultancy Services July 08 - 28 - Table 6 shows that during the period analysed the majority of people were assessed only once (63.8%). Two people received 4 assessments, six people had three assessments and 5 people had two assessments. Multiple assessments are an indication of the changing needs of the individual person. Table 6: Number of assessments undertaken per person

No. of No. of people assessments 4 2 3 6 2 5 1 23 Total 36

Table 7 below shows the recommendations of the ACAT. The numbers represent the numbers of assessments not the number of individuals. For example there were two recommendations for dementia specific residential care; however this was for one person.

This table shows that a high number of first assessments recommended high level residential care for the older person. Possible reasons for this trend may include:

The older person may have delayed the assessment as they wanted to remain in their own home or with family; A crisis (often a health crisis, such as a fall) may have occurred that quickly changed the health status of the older person; An assessment was not sought earlier to prevent or delay the need for high level residential care because the older person was not referred when their needs were low; The older person and their family were unaware of the assessment process and/or that the assessment process can provide access to home care not just residential care.

Table 7: Recommendation of assessments

RECOMMENDATION 1st 2nd 3rd 4th Dementia specific residential care 0 1 1 0 High level residential care 12 3 2 1 Low level residential care 2 2 0 0 Home care with or without home based or residential respite and residential respite only (1) 14 7 5 0 Incomplete assessment 6 1 0 0 Referral not accepted 2 0 0 0 Outcome not yet on database 0 0 0 1 TOTAL ASSESSMENTS 36 14 8 2

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FINDING The data and the consultations indicate that the community does not fully understand the process for accessing aged care services for both residential and in-home care, for example one community member commented that ‘they will be putting their name down soon” to access an aged care facility.

An important issue is that older people in the Central Highlands are not receiving an ACAT assessment early enough and the reasons for this need to be further explored.

4.6 REHABILITATION SERVICES FOR OLDER PEOPLE Throughout the consultations, there was some discussion about the need for step down or transition arrangements for the population, including mothers with new born babies, however there was minimal discussion about rehabilitation and transition care for older people.

This is not surprising as it as only been in recent years that there has been a much greater focus on providing rehabilitation and transition care for older people so that they can return home.

One of the reasons for this increased focus is that aged care providers were noticing that some older people who were admitted to residential care improved after receiving care in the facility to the extent that they could have returned home, but for many reasons this did not occur (eg the person’s house had been sold).

Triggers for entering residential aged care can include a fall or a urinary tract infection, which can temporarily cause the older person to become very frail and need a high level of support.

There are now many examples of programs that enable an older person to receive rehabilitation in a supported environment and then return home, which delays the need for early entry into residential care and these should be further explored.

FINDING Older people in the Central Highlands need access to rehabilitation/transition care in a supported environment so that they can return home, thus delaying the need for early entry into residential care.

MMT Consultancy Services July 08 - 30 - 5 SUMMARY OF CURRENT SERVICES PROVIDED IN THE REGION Table 8 shows the services available in the Central Highlands region and the funding sources. Services include hospital beds, high level residential aged care, home and community care services, health promotion and allied health.

It is acknowledged that this is not a comprehensive list of all services as there is no single, complete or up to date source of service information. The Evaluators therefore needed to approach a number of sources to collect this information and more services continued to be identified throughout the period of the review.

Table 8: Types of services currently available in the region

Funding source Services Based Coverage State Government 4 Hospital beds Ouse CH LGA Podiatry (1 day per quarter) Ouse CH LGA Social worker (0.2FTE) New Norfolk CH LGA Community health nurse (0.4) New Norfolk CH LGA Diabetes education (1 day per month) Royal Hobart Hospital CH LGA Family and child health nurse (on demand approx 1 day per month) New Norfolk CH LGA Geriatrician (1 day per month) Hobart Psychiatrist (1 day per 6 weeks) New Norfolk Volunteer Ambulance Service Bothwell Volunteer Ambulance Service Wayatinah Volunteer Ambulance Service Miena Australian 3 Community Aged Care Packages (6 hrs p/w) New Norfolk For the CH LGA Government Regional Health Service Ouse CH LGA Podiatry (1 day per month Bothwell 1 day per month Ouse) Social work (1 day p/f) Youth worker (4 days p/w) Mental health (1 day p/f) Primary Health/ Health Promotion (5 days p/w) Allied health (physiotherapist) unable to be filled National Suicide Prevention Strategy - awareness raising sessions Southern Midlands Council Covers CH LGA across the LGA General Practice South - New Dietician/ diabetic educator (via Diabetes Australia) CH LGA Norfolk Community Based Support Southern Central In home and centre based respite South Highlands Northern Central In home and centre based respite Family Based Care North Highlands Australian with State Government top up 4 nursing home beds Ouse CH LGA Australian and State Ouse and surrounding Community Nursing 3 days p/w) Ouse Government (HACC) areas Bothwell and Community nursing (5 days p/w) shared between Bothwell/Kempton Bothwell/Kempton surrounding areas Shared between Home Help (28 hrs p/f) New Norfolk Maydena & CH LGA 2 HACC programs to increase socialisation for older people Centralink CH LGA General Practice Ouse and surrounding GP 3.5 days per week Ouse areas Bothwell & surrounding GP 4 half days per week Bothwell areas Australian OUTSIDE OF REGION BUT AVAILABLE TO CH LGA 33 low care beds, 39 high care beds New Norfolk Derwent Valley 7 Community Aged Care Packages New Norfolk Derwent Valley 10 low care beds, 9 high care beds, 5 community care packages Southern Midlands MPC Southern Midlands 16 flexible high care places, 8 flexible low care places, 12 flexible Campbell Town Campbell Town Community Aged Care Packages

FINDING There is no up to date and comprehensive data base in the Central Highlands or the Australian or State Government that identifies all of the services available in the Central Highlands region. However, it is clear there is a gap between available services and those services the community needs.

MMT Consultancy Services July 08 - 31 - 6 HOSPITAL SERVICES PROVIDED This section describes the hospital activity for the 4 beds in the ODH and hospital activity for the Central Highlands community who attended hospitals outside of the municipality. 6.1 OUSE DISTRICT HOSPITAL The ODH has four hospital beds. The average occupancy rate over the last three financial years was 36% (see Table 9) for all separations in the hospital. The only way to increase occupancy rates is to reduce bed numbers or increase the number of admissions.

Table 9: Occupancy rates of ODH hospital beds Year Hospital rate 2003-04 55% 2004-05 28% 2005-06 32% 2006-07 48%

Over the last five financial years (note: 2007/08 is up to end of May 08) the number of admissions ranged between 42 and 64 and the number of patients 20 to 48. Table 10: No. of admissions and individuals Admissions Individuals 2003-04 64 48 2004-05 42 31 2005-06 44 27 2006-07 44 20 2007-08 60 28

In 2006/07 and 2007/08 the number of admissions was heavily influenced by one individual having multiple same-day admissions. The patient had 9 admissions in 2006/07 (7 of them same-day), and 13 admissions in 2007/08 (10 of them same- day).

The top 3 recorded Diagnostic Related Groups for patient separations in the ODH is summarised in Table 11. Table 11: DRG - ODH patients 2006/07 2006-07 Seps Respiratory 12 Blood disorders 10 Cardiac 8

6.2 LONG TERM TREND - ADMISSIONS Data from July 2003 through to May 2008 showed that there was an average of 4.23 admissions per month to the ODH.

Table 12 shows that during the period the number of admissions were low with no admissions for four months. These were June 04, April 06, Sept 06 and Oct 06.

There were 5 months when there was one admission (Apr 04, Jan 05, Feb 05, Mar 05 and July 06) and 6 months when there were two admissions (Nov 03; Oct 04; Feb 06; Mar 06; June 06 and Aug 06). The highest number was 10 months

MMT Consultancy Services July 08 - 32 - when there were 5 admissions. These were in the months Nov 03, April 05, Dec 05, Nov 06, Dec 06, June 07 and Feb, March and May 08.

During this period the GP admitting rights to the hospital changed three times.

Table 12: No. of admissions in the month X no. of months

Number of admissions No. of in the month months 0 4 1 5 2 6 3 8 4 9 5 10 6 5 7 5 8 3 9 2 10 2

Figure 7 shows the trend in admissions for the same period. There was a period from April to August 2006 when the numbers of separations were lower. This was when a GP from New Norfolk had admitting rights to the ODH.

This data shows that the trend in admissions is a pattern of “higher” numbers of separations being interspersed with lower numbers, however all numbers are still low.

Figure 7: Hospital admissions July 2003 to May 2008

Ouse - Admissions by month (hospital beds) 12 10 8 6 4 Adm 2 0

p v r l p v r l p v r l p v r l p v r 3 o 4 y Ju 5 ay Ju e o 6 y Ju 7 y Ju e o 8 a y Se N Ma Ma Se No 00 Ma M S N Ma Ma Se No 00 Ma Ma S N M Ma 200 200 2 200 2 200 an an an an Jul J J J J Jan

FINDING There are a small number of hospital beds in ODH. Occupancy rates and the number of admissions have been low for a considerable time and were even lower when a GP from New Norfolk had admitting rights to the ODH in 2006. In the last two years there has been an increase in admissions for same day procedures.

MMT Consultancy Services July 08 - 33 - 6.3 ALL HOSPITAL ADMISSIONS FOR CENTRAL HIGHLANDS RESIDENTS In 2004/05, 20 people living in the Central Highlands were separated from the hospital a total of 28 times. In 2005/06 24 people were separated from the hospital a total of 37 times and in 2006/07, 16 people were separated a total of 37 times. In 2006/07 six patients were admitted at least 2 times or more and 95% of the hospital bed days were occupied by people aged 65 years and over, demonstrating that the hospital is mainly used by older people living in the Central Highlands community.

Table 13 below shows that over the last 3 years the ODH discharged 7.4% of the total hospital separations for residents of the Central Highlands from all hospitals in Tasmania.

In 2006/07, 81% of patients in the ODH were from the southern part of the region2. This has been the main catchment area for the ODH hospital beds over the past three years.

2 Region of residence codes are in Attachment 1.

MMT Consultancy Services July 08 - 34 -

Table 13: Hospital Separations by Patient Residence and Hospital Patients from CH 2004/05 Hospital Region of Other % Using OUSE RHH Total Residence Hospitals Ouse E 5 137 15 157 3.2% N 7 1 8 0.0% S 17 278 10 305 5.6% SW 2 12 0 14 14.3% W 4 24 1 29 13.8% Total 28 458 27 513 5.5%

Patients from CH 2005/06 Hospital Region of Other % Using OUSE RHH Total Residence Hospitals Ouse E 4 157 17 178 2.2% N 6 1 7 0.0% S 25 207 4 236 10.6% SW 1 12 0 13 7.7% W 7 15 0 22 31.8% Grand Tota 37 397 22 456 8.1%

Patients from CH 2006/07 Hospital Region of Other % Using OUSE RHH Total Residence Hospitals Ouse E 3 133 6 142 2.11% N 10 0 10 0.00% S 30 211 20 261 11.49% SW 1 16 0 17 5.88% W 3 17 0 20 15.00% Totals 37 387 26 450 8.22%

FINDING There is a lack of demand for the hospital beds in the ODH and the majority of people are going to other hospitals outside of the region. In 2006/07, 91.8% of hospital discharges were for people from the Central Highlands who went to a hospital outside of the ODH (ie 413 of 450 patients). This excludes any private hospital activity.

MMT Consultancy Services July 08 - 35 - Diagnosis on admission for all hospital separations for Central Highlands residents in 2006/07 is shown in Table 14. The highest numbers were for lung cancer.

Table 14: Diagnosis on admission for separations of Central Highlands Residents in ODH and other hospitals Other Diagnosis on Admission ODH Total Hospitals CA LUNG 34 9 43 CONFINEMENT 18 18 PAIN CHEST 18 18 COLONOSCOPY 15 15 UNQUALIFIED NEONATE 14 14 CA BREAST 9 9 ANAEMIA 3 5 8 RENAL FAILURE 8 8 GASTROSCOPY/COLONOSCOPY 8 8 BRONCHOSCOPY 5 5 BIPOLAR DISORDER 4 4 DECAYED TEETH 4 4 LOW BACK PAIN 4 4 PAIN BACK 4 4 PAIN KNEE 4 4 ABDO PAIN 3 3 ABDOMINAL TAP 3 3 ANXIETY 3 3 BBA 3 3 CARPAL TUNNEL SYNDROME 3 3 DEPRESSION 3 3 GASTROENTERITIS 3 3 IHD 3 3 IRON OVERLOAD 0 5 5 OTHER (Less than 3 Cases/Condition) 74 18 92 TOTALS 250 37 287

6.4 24/7 ACCIDENT AND EMERGENCY SERVICE A recent review of the 24/7 emergency service by the DHHS during the period 1/02/08 – 31/03/08 (60 days) showed that there were 59 presentations at the ODH, accident and emergency service (Table 15)

Table 15: Number of presentations by triage category

Triage Category Presentations* 1 4 2 3 3 1 4 5 5 37 * (NB: 9 attendances not triage coded)

The reasons for presentation and the triage category are outlined below.

MMT Consultancy Services July 08 - 36 -

Triage 1 (highest acuity) included shortness of breath, chest pain, severe allergic reaction. Triage 2 - included trauma post motor vehicle accident and allergic reaction. Triage 3 & 4 - included a patient with a sore hip post a fall, infected wounds, motor vehicle accident injury to arm. Triage 5 - included planned wound care, planned ECG, lower limb injury (sports related), blood tests.

The review also identified an instance of a critically ill client with respiratory distress who presented to ODH. An ambulance was called and in the interim, the solo registered nurse tried to insert an IV cannula without success.

The findings of the review include the following points.

The emergency service relies on having access to registered nurses with a good understanding of primary and secondary assessment, sound emergency triage skills, good knowledge of how to use emergency equipment and good knowledge of the processes for accessing after hours medical and emergency response services. Whilst Regional Hospital nurses have these skills, very few rural hospital nurses have this experience and background. It is becoming increasingly difficult to recruit agency nurses with rural emergency background and experience. The current staffing situation is not adequate to ensure there are sufficient registered nurses with adequate skills to ensure 24/7 cover (and cover for sick leave, unplanned extended leave, annual leave or leave for continuing education).

Finding 74% of people who presented to the accident and emergency service were for planned care that did not need to be undertaken at an accident and emergency facility.

MMT Consultancy Services July 08 - 37 - 7 QUALITY AND SAFETY There were 64 adverse events reported in the hospital since 2005 (Table 16). The number of adverse events fell significantly in 2007.

Table 16: Adverse events 2005 through to 2008

Incident Type 2005 2006 2007 2008 Total Behaviour – abuse by Resident 1 1 Behaviour – assault by Resident 1 3 4 Behaviour – verbal abuse by Resident 1 1 Burn 1 1 Communication Issue 1 1 Diagnostic Test 1 1 Fall 20 5 4 1 30 Incident Type 1 1 Medication 8 4 12 Missed Diagnosis 1 1 Needle stick Injury 1 1 Pressure Area 1 1 2 Resident Rights Issue 1 1 Skin Tear 1 1 2 Wandering 1 4 5

Total 24 28 9 3 64

One of the incidents in 2007 was a reportable death as per the Coroners Act 1995 and is the subject of a Coronial Enquiry. The DHHS undertook a review of the incident and the details were provided to the Steering Committee. The Members noted the quality and safety issues relating to the incident, however it was considered inappropriate to include all of the details in the final written report.

In summary the DHHS report identified that to ensure quality of care a hospital must have:

Trained staff, Multiple procedures that must be adhered to at all times; Ongoing communication between the GP and the staff at all times; Equipment that is kept functional at all times; and A responsive ambulance service.

These are the types of pressures and problems that small hospitals experience. In addition, there must be enough throughput in a hospital to maintain the skills of staff.

All of the above is required in the ODH regardless of the number of beds in the hospital.

Finding Any future delivery model for the Central Highlands must be able to ensure that ongoing quality systems and procedures are implemented and maintained.

MMT Consultancy Services July 08 - 38 - 8 AMBULANCE SERVICES & GP ASSIST This section of the report provides information on the volunteer and paramedic ambulance services and the GP Assist service. 8.1 AMBULANCE SERVICES In the last 18 months ambulances have transported almost all patients living in the Central Highlands to hospitals other than ODH (Table 17).

Table 17: Number of ambulance carries volunteer and paramedic Referred to Referred to Total CH Type of Transport ODH Other Transports Emergency 3 373 376 Urgent 0 154 154 Other 0 27 27 Total 3 554 557

The Bothwell, Miena and Wayatinah Volunteer Ambulance services have transported very few patients over the last 5 years (Figure 8).

Figure 8: Ambulance transports –volunteer and paramedic 2001/02 – 2005/06

Ambulance Transports 2001-2 to 2005-6 1500

1400

1300

1200

1100

1000 Emergency Urgent 900 Other

800

700

600 Number ofTransports 500

400

300

200

100

0 2001_02 New Norfolk New 2001_02 Norfolk New 2002_03 Norfolk New 2003_04 Norfolk New 2004_05 Norfolk New 2005_06 Bothwell 2001_02 Bothwell 2002_03 Bothwell 2003_04 Bothwell 2004_05 Bothwell 2005_06 Miena 2001_02 Miena 2002_03 Miena 2003_04 Miena 2004_05 Miena 2005_06 Wayatinah 2001_02 Wayatinah 2002_03 Wayatinah 2003_04 Wayatinah 2004_05 Wayatinah 2005_06

Year and Station

MMT Consultancy Services July 08 - 39 - There were 86 volunteer ambulance trips performed in 2006/07 in the Central Highlands region, (including non-urgent). Paramedic services in the south of the State (2.5 full time people) undertook between 1,311 and 1,699 trips per ambulance station in the same year.

In the 18 months ending in December 2007 there were 114 ambulance callouts to the region (including non-urgent) that were responded to by ambulances based in the Central Highlands and outside the Central Highlands. Three emergency carries were taken to the ODH.

FINDING The number of ambulance carries by volunteer ambulances or ambulances coming into the region do not justify a full paramedic service in the Central Highlands.

Nevertheless, the community has significant concerns about the response times of the ambulance service into the area, regardless of the outcome of ODH this issue needs to be addressed.

The Evaluators are aware that there is a proposal to offer emergency response training in a number of areas such as:

Train community members as a first response service; Offer volunteer ambulance training to staff; Offer a higher level of training to nurses so that they can respond at a level higher than a volunteer ambulance; and Create a new nursing/paramedic degree.

FINDING The response times from New Norfolk need to be improved urgently. Opportunities to increase emergency response training for the community, staff and nurses will assist to improve emergency responses. The need and possible implementation of a volunteer ambulance service at Ouse to compliment paramedic services should be explored.

8.2 GP ASSIST GP Assist is an after hours telephone service that provides access to general practitioner advice between the hours of 6.00pm and 8.00 am.

GP Assist is a free service to rural GPs who choose to use it (some GPs prefer to provide their own after hours service). GPs using the service transfer their phone line directly to GP Assist's 1300 number or they may use it more selectively. If a GP patient rings their GP the call will go directly through to GP Assist and advice is received.

This does not occur in the ODH because there is only one telephone line in the hospital. If a person rings for the GP the hospital will answer the call. If assistance is needed then the nurse will ring GP Assist.

Feedback about the responsiveness of GP Assist from the ODH staff was generally positive. The GP in Ouse also said that it was a helpful service.

MMT Consultancy Services July 08 - 40 - The patients of the GP in Ouse are not fully aware of this service as the call is screened by a nurse in the hospital; hence it is believed that that the hospital is providing this service rather than GP Assist.

The GP Assist number is not displayed prominently. One community member commented “it is like a hidden service and therefore Ouse hospital becomes the defacto centre for calling in/telephone or treatment minor ailments 24 hours a day”.

FINDING Separate telephone lines are needed in the hospital so that when people ring their GP after hours the call goes directly to GP Assist. This arrangement will provide quicker access to GP advice, which could be needed in an urgent situation. The availability of GP Assist needs to be promoted in the community.

The Evaluators are aware that a National Call Centre will be established across Australia within the next year. When this occurs it must be well promoted, particularly to people living in rural communities and people traveling or working temporarily in rural areas.

Finding The Evaluators are aware that a National Call Centre will be established across Australia within the next year. When this occurs it must be well promoted, particularly to people living in rural communities and people traveling or working temporarily in rural areas.

MMT Consultancy Services July 08 - 41 - 9 AGED CARE SERVICES This section of the report describes the aged care services provided in the region. 9.1 RESIDENTIAL HIGH CARE PLACES IN ODH The occupancy of the residential high care places in ODH is high. Over the last 4 financial years the residential places were occupied an average 94.5% of total bed days (Table 18). Table 18: Percentage occupancy of residential high care places Year Aged Care Bed 2003-04 98% 2004-05 85% 2005-06 96% 2006-07 99%

The aged care facility in the ODH has been accredited until May 2009. The assessed level of need of the residents has been increasing, although the numbers of people are small.

There were 11 residents in the ODH between March 1999 to June 2008. Five of the 11 residents came from the northern part of the Central Highlands region, indicating that older people living across the Central Highlands are accessing the residential places.

The length of stay for the residents during that time and the reasons for discharge are outlined in the table below. Table 19: Aged care residents LOS and reason for discharge LOS REASON FOR YEARS DISCHARGE 6.58 Deceased 4.83 Deceased 6.67 In ODH 4.33 Transferred 1.08 Deceased 0.17 Deceased 2.33 Transferred 1.25 Deceased 1.92 Transferred 1.92 Transferred 0.75 Transferred

The community has argued that their residents live longer because of the quality of care provided to the residents in the ODH.

The table below shows the average length of stay of residents in both low and high care places for all States and Australia for the past 4 years. This data cannot be broken down between low and high care places, however it would be expected that people in low care places would have had a longer length of stay compared to people in high care places. The average length of stay in Tasmania ranged from 36.3months in 2004 through to 36.6 in 2007.

Additional length of stay information was gathered from two aged care providers who operate residential high care places in Tasmania. One provider stated that

MMT Consultancy Services July 08 - 42 - their residents’ length of stay in a high care place is up to 9 months and the other aged care provider advised that residents stay between 6 to 9 months.

Table 20: LOS (in months) of low and high care residents 1999 – 2008 Ave. total LOS 2004 2005 2006 2007 NSW 35.0 35.3 35.9 35.9 VIC 35.8 36.8 36.5 37.4 QLD 36.9 36.4 37.5 37.8 SA 34.4 34.3 34.5 36.2 WA 36.5 37.4 38.2 38.9 TAS 36.3 37.4 37.2 36.6 NT 34.9 34.7 37.8 49.6 ACT 41.5 40.6 39.0 38.5 Australia 35.7 36.0 36.4 37.0

FINDING Due to the long length of stay of a number of residents in the ODH, the Evaluators consider that some residents in the ODH may have been assessed inappropriately for high level residential care and that if rehabilitation, transition arrangements or alternative safe accommodation was available, such as an independent living unit closer to facilities, this would have been a more appropriate option.

FINDING Five of the 11 residents came from the northern part of the Central Highlands region, indicating that older people living across the Central Highlands are accessing the residential places.

9.2 COMMUNITY AGED CARE PACKAGES There are 3 Community Aged Care Packages (CACPs) allocated to the Central Highlands and managed from New Norfolk.

A spot audit of the CACPs showed that very few people in the Central Highlands have been waiting to access a CACP as shown in the table below.

Table 21: Waiting list for CACPs

Date No. of people in CH on waiting list July 06 0 January 07 0 July 07 2 January 08 0

In the southern part of the State there are approximately 498 packages with 120 people on the waiting list at any one time. This shows that there is a need for more CACPs in this area.

MMT Consultancy Services July 08 - 43 - From the consultations it was apparent that people lack understanding of the role of the ACAT in providing entry to home care services. There also appears to be a lack of understanding about the outcome of an ACAT assessment. Many people appear to be unaware that an ACAT assessment is a recommendation and that the older person has a choice if they want to pursue the recommendation to access home care or residential care depending on the outcome of the recommendation.

FINDING Additional CACPs are needed for the southern planning region. The community and service providers in the region require more information about the role of the ACAT. The option of home care needs to be further promoted across the region.

9.3 HOME AND COMMUNITY CARE PROGRAM It is estimated that the Home and Community Care (HACC) target population is 258 people. In 2006/07 155 clients received a HACC service. This represents 60.0% of the HACC target group.

The table below shows the percentage of people who received HACC services in 2006/07. A higher percentage of people living in Bothwell received HACC services.

Figure 9: Percentage of people who received HACC services in 2006/07

45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

L E A E E L ON L NA ON E EN ND AK ARK T T K A L EON P DA L S GO LA MIENA OUSEKL HWE R E A EN MI R C T B L L GRE DY NT L HA OW TRTE BO A L WAYATINAH EE E IN STRI BR RO D B HOL

Figure 10 below shows the difference between the percentage of people who received HACC services in 2006/07 and the percentage of the population aged 65 years and over (where population data was available; that is, towns with small populations could not be calculated because Census data is not available).

The chart shows that less people aged 65 years and over are receiving HACC services in Ellendale, Hamilton, Miena, Wayatinah and Westerway.

MMT Consultancy Services July 08 - 44 - Figure 10: Difference between percentage of clients receiving services and percentage of the population aged 65+

WESTERWAY

WAYATINAH

OUSE

MIENA

HAMILTON

GRETNA

ELLENDALE

BOTHWELL

-10.0% -5.0% 0.0% 5.0% 10.0% 15.0% 20.0%

Table 22 below shows the average hours of HACC services per client for the 2006/07 financial year by region, for the whole State and the bottom 10 Statistical Local Areas (SLAs). The Central Highlands was the 10th lowest SLA with HACC clients receiving an average of 7.36 hours of HACC services per year compared to 17.32 average hours per client across the State. Table 22: Comparison of average hours per client for regions, the State and the bottom 10 SLAs SLA Name Average Hours per client 06-07 Central Highlands (M) 7.36 Burnie (C) - Pt B 6.43 Latrobe (M) - Pt B 5.85 Derwent Valley (M) - Pt B 5.38 Northern Midlands (M) - Pt B 4.39 Tasman (M) 4.25 Meander Valley (M) - Pt A 3.92 Central Coast (M) - Pt B 3.84 George Town (M) - Pt B 3.62 West Tamar (M) - Pt B 1.08 Northern Tas. 20.06 North West Tas. 17.69 Southern Tas. 15.56 Tasmania 17.32

This financial year funding was approved for additional personal care in the Central Highlands ($56,000 FYE). However, the services are not yet being provided in the region.

Centralink, a volunteer group, which commenced operations in 1993 has done an excellent job to attract funding, particularly funding from the HACC program for

MMT Consultancy Services July 08 - 45 - older people in the community. This includes a Telelink program linking isolated people in the community and a social support program (once a month).

FINDING Older people in the region are receiving less HACC services compared to other older Tasmanians.

More HACC services are required across the Central Highlands and the services need to be further promoted to the community. 9.4 RESIDENTIAL AGED CARE PLACES As at February 2008, the average age for residents in high care places across Australia was 83.7 years and the average age for residents in low care places was 84.2.

One in four older people aged 70 years and over make some use of aged care services. Of those that do, most use community care provided in their own home. At any one time, there are approximately one in ten older people who have left their home to receive care in a residential care facility3.

As at June 2007, there were 169,594 operational residential places across Australia. This represents approximately 8.7% of the population aged 70 years and over. The Australian Government plans for aged care provision on a regional basis and within Tasmania; there are three regions the South, North and Northwest. In each of these the benchmark for aged care provision is for 44 High Care, 44 Low Care and 25 packages (mixture of CACP, Extended Aged Care in the Home (EACH, and EACH Dementia) for every 1000 people over the age of 70 years.

The Southern Region, which incorporates the Central Highlands, exceeds the benchmarks in both low and high residential care places and falls short of the community packages benchmark.

In Tasmania an aged care planning region equates to each of the three ex- telephone areas and the Central Highlands local government area is located in the Southern region. If the current aged care planning benchmark was to be applied to the Central Highlands there would be a need for approximately 22 aged care places (including community care) to be available for access for eligible people across the Central Highlands. This figure should however be interpreted with caution as the Australian Government does not plan for aged care places allocation at the local government area level.

The ODH has had 6 residential places and there are 3 community packages, therefore if the community needs access to approximately 22 aged care places in the Southern region, then some older people must be accessing residential services outside of the Central Highlands.

The 2006-07 Annual Report for the Department of Health & Ageing notes that the Southern Tasmania aged care planning region which incorporates the Central Highlands exceeds the benchmarks in both low and high residential aged care places and is slightly under the ratio for community care places.

3 Aged Care in Australia, May 2006, Department of Health and Ageing

MMT Consultancy Services July 08 - 46 - FINDING The Southern Region, which incorporates the Central Highlands, exceeds the benchmarks in both low and high residential care places at the present time but it falls short of the community packages benchmark.

MMT Consultancy Services July 08 - 47 - 10 OTHER SERVICES This section describes other services provided, including GPs, the Regional Health Service, carer support and business development.

10.1 GENERAL PRACTICE There are two General Practitioners in the Central Highlands. One based in Ouse and the other based in Bothwell. Both GPs work in these locations part- time. The GP in Ouse contracts a Practice Nurse one day per week. The GP in Bothwell does not have a Practice Nurse.

The GPs are 2 of only 5 GPs that can dispense pharmaceuticals in Tasmania. The GP in Ouse receives funding from the State for the provision of medical services for the in-patients of the ODH.

There has been a difficulty in attracting a GP in Ouse over recent years, although the situation is currently stable. In addition, a medical officer living part-time in the Central Highlands has recently accepted an offer from the GP in Ouse to participate in an “on call” service to provide, at a minimum, a telephone standby for the hospital 24 hours per day.

The Primary Health Clinical Privileges Committee, DHHS has granted full privileges for 12 months, subject to a few conditions. This will provide locum support for the GP in Ouse to go on holiday, as well as provide some weekend on-call back up.

The Evaluators consider that the current GP facilities in Ouse are inadequate to provide a basic general practice service.

The retention of GP services in rural areas is not contingent upon the existence of a rural hospital. There is no evidence that GPs are generally attracted to rural hospitals. Moreover, the GP Workforce and private GPs seeking to recruit to their practice have experienced doctors not accepting positions in rural communities if there is a small rural hospital. Reasons include not wanting to be responsible for inpatient care and the risks associated with that and not wanting to provide a hospital on call service.

Both GPs are sole practitioners; however there is evidence that a more sustainable option for general practice, particularly in rural areas, is through larger GP Practices as it provides peer support.

Moreover, with the support of Practice Nurses, particularly for chronic disease management and wound clinics, this would provide a positive environment for attracting staff.

FINDING The GP facilities in Ouse require expansion to operate more effectively.

The Evaluators consider that Group Practice, with the support of Practice Nurses is more sustainable in the longer term to balance life/work and support contemporary practice for individual GPs.

MMT Consultancy Services July 08 - 48 - 10.2 REGIONAL HEALTH SERVICE The Regional Health Service at Ash Cottage based in Ouse provides a wide range of health promotion activities targeted at priority groups of the population. The types of activities relating to health promotion are outlined in Section 22 as an Attachment to this report. Programs have been targeted at priority health needs such as mental health, social integration, life skills, nutrition, interpersonal skills and health and well-being. Other programs target suicide prevention, women’s health and well-being and parenting.

The Regional Health Service also provides podiatry one day per month and a mental health nurse one day per fortnight.

In the period July to December 2007, the podiatrist had 147 client visits in Bothwell and 132 client visits in Ouse. In the same period the community mental health nurse saw 36 clients, 4 clients cancelled and 8 clients did not attend. The clients were from Hamilton, Ouse and Osterly.

While not under the Regional Health Service another visiting mental health nurse visited 4 people in the Ouse and Ellendale area and a psychiatrist utilises Ash Cottage to meet with clients in the area every six weeks.

The Regional Health Service is well regarded by the people in the community who are aware of the service, however at the present time the ODH and the Regional Health Service operate as separate entities.

FINDING The Regional Health Service based at Ash Cottage should be integrated into the future service delivery model for the Central Highlands.

10.3 CARER SUPPORT AND RESPITE In the last 12 months 9 people received in-home respite and residential respite through the Carer Respite Centre in the Southern Central Highlands. Family Based North currently has no clients in the Central Highlands area.

FINDING There are significant gaps in support and respite for carers across the Central Highlands.

10.4 TRANSPORT Funding was raised for the “Tweety Bus” based in Ouse, which is either driven by volunteers eg shopping trips to New Norfolk or can be used by other members of the community. In addition, the bus at the ODH has recently been replaced and has wheelchair access.

The need for improved transport was a strong theme throughout the consultations. The State Government is currently examining the potential for significant improvements in transport options across Tasmania, including one telephone number to call to access a service and making sure that all transport that is currently available is being fully utilised.

MMT Consultancy Services July 08 - 49 - FINDING The Evaluators highly support the DHHS initiative to improve access to transport as long the guidelines are flexible enough to incorporate the needs of the community.

10.5 ATTRACTING FUNDING Centralink and more recently the Regional Health Service (through Go Highlands) have done an excellent job in attracting important funding to the region. The Medical Services Committee has also contributed significantly to lobby and raise awareness of the needs of the community.

However, there are many health and aged care program areas under-funded across the region (eg HACC and CACPs) because there have not been the resources to draft funding submissions or develop program models to attract funding.

Networking and creating partnerships to deliver services has only recently been a focus in the region through the Regional Health Service and this needs to be increased in order to improve the range of health and aged care services available.

FINDING Regardless of which option is implemented, the Evaluators have observed that there is a need for a dedicated person to provide the leadership required to build networks, create partnerships and attract increased funding to the region for improved access to health and aged care services.

10.6 AVAILABLE FACILITIES There are good facilities in the region, such as the Ouse Golf Club premises and the Miena Community Hall.

There are five units next to the ODH managed by the DHHS that could be potentially used as independent living units for older people.

An assessment of the units indicates that there is wheelchair access, although the kitchens will need to be modified and the units updated.

An interim costing has been undertaken by Housing Tasmania of $66,500 to upgrade the units (note that this was a desktop analysis and not all units may require the same level of work).

FINDING There are good facilities in the region, such as the Ouse Golf Club premises and the Miena Community Hall that could be better utilised in the future.

There are five units next to the ODH that could be upgraded (at a cost of up to $66,500) for use as independent living units for older people.

10.7 OTHER RESIDENTIAL AGED CARE FACILITIES Information was collected from three residential aged care facilities (nearby but outside of the region) regarding waiting lists. The information is provided below.

MMT Consultancy Services July 08 - 50 - FACILITY ONE There are usually 4 to 6 people on the waiting list at any one time for a residential high care place. The waiting time is on average 90 days. There are usually no more than 8 people on the waiting list for a low care place and the waiting period can be up to 150 to-200 days. There is rarely one person waiting to access a Community Aged Care Package.

FACILITY TWO There are usually no more than 6 people waiting for an aged care place.

FACILITY THREE If there is a waiting list, there is never more than 2 people on it, although the waiting period can be approximately 90 days.

MMT Consultancy Services July 08 - 51 - 11 CURRENT STAFFING The three tables below show the staffing levels at the ODH, the Regional Health Service and Visiting Specialists as at April 2008.

Table 23:ODH Staff

Permanent Casual Permanent Position title FTE relief FTE Total FTE vacant FTE (acting DON Director of Nursing 1 0.15 1.15 since July 06) Admin Assistant 1.08 1.08 nil Clinical Nurse 1 1 1

Registered Nurse 3.9 0.6 4.34 0.16 Enrolled Nurse 2 0.36 2.36 nil Hospital Aide 3.41 0.63 4.04 nil Cook 1 0.2 1.2 nil Cook/Domestic 1 1 1 Non-trades Cook/ Domestic 2 0.36 2.36 0.38 Maintenance Officer 1 0.15 1.15 nil Diversional Therapist 0.32 0.32 nil Rural Medical Practitioner 0.11 nil

Urgent issues relating to staffing at the ODH have been reported consistently since March 2005.

Efforts have been made to fill positions by the DHHS, with positions re-advertised as suitable applicants have not been found. The DON position was advertised in June 2006, October 2006 and then January 2007 well before the announcement of the Primary Health Care Plan and no suitable applicant could be appointed.

The lack of a critical mass of qualified personnel in the ODH means staffing shortages will continue to occur, if not now, then in the medium term. It is not the actions and recruitment processes of the DHHS that has created the staffing problems at the ODH, although it is acknowledged that the uncertainty of the future of the hospital would have reduced the interest of people applying for permanent positions.

There are some positions that have not been advertised such as the cook/domestic. This was delayed as the hours were shared out amongst the remaining staff. The funding for the position and the hours worked is reflected in the total expenditure for salaries for the site.

The Director of Nursing (DON) at ODH routinely struggles to fill the monthly rosters and a number of nurses are now working greater hours than they would like; others are traveling from New Norfolk Hospital to fill shifts and local agency nurses are being used.

MMT Consultancy Services July 08 - 52 - Staff of the hospital have accrued a significant level of annual and long service leave which is poor management practice and can no longer continue. Agency nurses have been contracted as well as nurses from other hospital sites to enable the hospital’s services to continue; this impacts on the continuity and quality of care of patients and residents.

The acting site DON has undertaken nursing shifts to fill gaps in the roster. Under extra-ordinary circumstances gaps in the roster have been filled by nurses from the Royal Hobart Hospital and North West Regional Hospital.

DONs have reported that the constant demand of managing the rosters has impacted negatively on their own health and wellbeing.

Two fulltime positions have been recently filled on a temporary basis, however local and interstate nursing agencies continue to be approached to fill shifts on a short term basis. The situation is not sustainable.

In addition, back fill to enable staff to attend training is critical to ensuring ongoing quality care.

Whilst recruitment efforts continue, it is likely that given the location of ODH and the shortage of registered nurses prepared (and skilled) to work in rural and remote areas, that nurse staffing issues will continue and become increasingly critical. It is highly likely, with the current staffing profile at ODH, that registered nurse staffing 24/7 will not be able to be maintained. This situation could arise at anytime due to unplanned sick leave and lack of local casual registered nurses or it could occur with some advance warning (e.g. shifts unfilled in the following week and inability to find relief staff).

Tasmania is experiencing significant difficulties in recruiting and retaining nurses, particularly in rural and remote areas and it is expected that this will be a long term problem. There are many examples of sites across Tasmania that are experiencing similar difficulties, particularly those with a lack of a critical mass.

FINDING Tasmania is experiencing significant difficulties in recruiting and retaining nurses, particularly in rural and remote areas and it is expected that this will be a long term problem. If the hospital remains open many of the issues relating to managing the roster will certainly continue.

MMT Consultancy Services July 08 - 53 - Table 24: Regional Health Services Staff

Position title Fixed term contract to 30 June 2008 Primary Health Coordinator 1

0.8 (changed from 0.6 to 0.8 for last Health Promotion Worker quarter of 07-08 year) Administrative Support 0.5 Podiatrist 0.1 Mental Health (psychologist) 0.1

Allied Health (physiotherapist) vacant

Staffing at the Regional Health Service has been relatively stable, although a position for a physiotherapist has been unable to be filled since 2006. Table 25: Visiting DHHS Allied Health Staff

Position based at other Position title FTE DHHS site One day per Podiatrist quarter Royal Hobart Hospital Social Worker 0.2 New Norfolk CHC Community Health Nurse 0.4 New Norfolk CHC Diabetic Educator 1 x monthly Royal Hobart Hospital Family & Child Health On demand – Nurse approx monthly New Norfolk CHC

There are a number of visiting staff that come into the region but these services are either well booked in advance or at times cancelled.

MMT Consultancy Services July 08 - 54 - 12 COST OF HOSPITAL BEDS AND AGED CARE PLACES The actual cost of the hospital has been steadily increasing over the past three financial years and there have been cost overruns. Table 26 shows that the average cost per bed has risen from $113,554 in 2004/05 to $127,999 in 2006/07. Furthermore, the income received for the Australian funded residential high care places was $49,164 in 2006/07 showing that the State is heavily subsidising these residential care places.

Table 26: Average cost per bed INCOME 2004/05 2005/06 2006/07 Income from Aust Govt & residents fees for 6 NH beds 292,750 344,083 294,984

Income from 4 hospital beds (fees are charged after 28 days) 608 8,251 52,062 Other revenue carry overs 50,756 8,073 3 EXPENDITURE Salaries and wages & other expenses 1,479,651 1,525,479 1,627,041 TOTAL COST 1,135,537 1,165,072 1,279,992 Budget from DHHS 937,706 1,064,000 1,145,945 Overrun 197,831 101,072 134,047 COST PER BED (10) 113,554 116,507 127,999

There are different ways in which gross and net expenditures can be measured including undifferentiated totals, cost/bed; cost/bed day; and cost/patient. Depending whether or not occupancy rates are included in the estimations the costs of hospital beds and residential aged care places, bed days and patients will be the same or will differ.

The cost per patient is between $62,000 and $81,400 if it is assumed that the hospital patients and aged care residents in ODH receive the same amount of nursing care. If differences in occupancy rates are considered, the cost per hospital patient is between $19,500 and $40,700 per patient; and the cost per aged care resident is between $192,000 and $244,000 per resident. The lower values apply net expenses and the higher values apply total expenses unadjusted for revenues.

FINDING It cost approximately $1.3m to run the Ouse District Hospital in 2006/07, including income of $295,000 received from the Australian Government and resident fees for the 6 aged care beds (this does not cover the actual cost). Other income of $52,000 was received in inpatient fees for the 4 hospital beds. The State contribution was $1.145 m.

There was a budget overrun of approximately $135,000. This was mainly due to employing agency staff to address the nursing workforce issues.

In 2006/07 on average, each bed cost $128,000 net to operate (excluding the overrun and regardless of whether the bed was being utilised).

The DHHS is subsidising the costs of the aged care places considerably.

MMT Consultancy Services July 08 - 55 - 13 OPPORTUNITY COSTS, SCALE AND PATIENT SAFETY A comparison of Ouse total, average or bed costs with other facilities is difficult because there are very few facilities of this type and size in Tasmania or in Australia. This section describes the opportunity cost of providing inpatient services at Ouse, economies of scale and patient safety.

13.1 Opportunity Cost As indicated above, it costs $1.6m gross and $1.3m net to treat 16 people in acute beds (separated a total of 37 times) plus 4 residential patients. Table 27 shows how many patients could have been provided with community care if the inpatient costs had been allocated to alternative services for other population groups. The opportunity cost of providing inpatient services at Ouse is not providing a full year of services for 100-130 CACP clients or 220-290 HACC clients in the region.

Table 27: Opportunity cost

Ouse Costs/person/year Average Cost/Aged Care Average Cost/Patient Average Cost/Hospital Patient Resident Low Cost High cost Low Cost High cost Low Cost High cost $ 62,000 $ 81,400 $ 19,500 $ 40,700 $ 192,000 $ 244,000 Alternative Av $/Person/Year People not provided alternative services/Patient treated in Ouse/Year Service CACPa $ 12,400 5.0 6.6 1.6 3.3 15.5 19.7 HACCb $ 5,600 11.1 14.5 3.5 7.3 34.3 43.6 Alternative Av $/Person/Year Total People not provided alternative services/Year Service CACPa $ 12,400 100.0 131.3 25.2 52.5 61.9 78.7 HACCb $ 5,600 221.4 290.7 55.7 116.3 137.1 174.3

13.2 Scale and Patient Safety Even if direct comparison of costs show that Ouse has the lowest cost per bed (which it does not) such a comparison is not in itself meaningful because cost- effectiveness does not depend on cost alone. It depends on both the cost and the output or outcome. In this regard beds or bed days are not outputs or outcomes but resources used to generate an output or outcome.

For hospitals the correct measure is cost per complexity weighted case treated or cost per complexity weighted patient. In this type of comparison all health care facilities with less than 50 beds (some studies suggest 100 beds) are not cost effective because the total cost is determined more by fixed costs which have to be apportioned to a relatively small number of clients. In this type of comparison, smaller facilities are at the greatest disadvantage. Because of its size, Ouse is at the least cost-effectiveness end of the scale.

Patient Safety is directly affected by scale and the scale of the Ouse hospital threatens patient safety. There are a number of reasons for this:

Availability of Staff The availability of staff cannot be guaranteed; and nursing staff on duty have competing priorities when caring or treating patients.

The community has convincingly argued that staff could be available if all circumstances are right and the consultants agree this argument has merit.

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However, even if staff can be found in the short term, the staffing situation will always remain tenuous because staffing shortage is not just a local issue for Ouse. It is a regional, state, national and international issue. It is not realistic to assume that the Ouse Community has found a permanent viable solution to the problem of staffing shortages.

Clinical Experience and Skill Mix The Evaluators assume all staff at the hospital have the skills and experience necessary to practice safely in an isolated community. However, the region lacks the critical mass of patients required to ensure clinical competence can be maintained. (In fact, this is a key reason why rural areas find it difficult to attract and maintain doctors.) It is possible to supplement local clinical experience by providing staff with short-term clinical experience in high-volume facilities. However, this contributes to staffing pressures discussed above.

Small facilities cannot provide the skill mix required to maintain safe services. Patients are already transported when staff cannot deal with clinical conditions.

Emergency Care There is no effective emergency care at Ouse. The number of emergency ambulance carries into Ouse is insignificant and almost all emergency cases have been transferred to larger facilities out of the region. The facility at Ouse does not have the capacity to deal with major medical emergencies.

FINDING The real cost of providing inpatient services for a very small number of patients is not providing community care and preventive services for a substantially larger number of other people.

Inpatient facilities such as those provided at ODH are intrinsically inefficient because of their size. Making comparisons with facilities of equal size is comparing degrees of in-efficiency.

The Ouse Hospital is inefficient because of its diseconomies of scale, and the scale of operations directly threatens the safety of patient care.

MMT Consultancy Services July 08 - 57 - 14 OUTCOME OF COMMUNITY CONSULTATIONS This section of the report outlines the outcomes of the community consultations and the communities view if the hospital was closed. 14.1 FIRST CONSULTATION The first round of consultations were held in the week of the 28th April 2008. Table 28 below shows the number of people in the Central Highlands that attended the consultations.

Table 28: No. of people in the Central Highlands who attended the 1st consultations

1st Consultation No. of people Ouse 28/4/08 86 community members Wayatinah 29/04/08 9 community members and 5 other interested stakeholders Bothwell 30/04/08 11 community members and 4 other interested stakeholders Miena 1/5/08 7 community members and 6 other interested stakeholders * Other interested stakeholders included members of the Central Highlands Council and the Medical Services Committee.

The purpose of the first consultation round was to share with the community information about the population in the Central Highlands and to gain feedback on the health and aged care needs of the community.

The results of the consultation are outlined in Section 4.1.

At the same time submissions were called on the 19th April 2008 with a closing date of 7th May. Ten submissions were received from 11 people all living in or around the southern part of the Central Highlands. One submission was received from an organisation for the region. A copy of a letter of support from a tourist who regularly visits the area was also provided to the Consultants. All of these submissions were in support of retaining the hospital.

14.2 SECOND CONSULTATION The Evaluators returned to the Central Highlands in the week of the 2nd June 2008 to share further information that had been collected to date, to outline the options for the future delivery of health and aged care services in the Central Highlands and to seek feedback on the benefits and the risks of each of the options. The options were outlined in a booklet that had been drafted by the Evaluators and distributed to the community by the Central Highlands council.

Table 29: No. of people in the Central Highlands who attended the 2nd consultations

2nd Consultation No. of people Ellendale 4/6/08 55-60 community members Ouse 4/6/08 70 community members Bothwell 5/6/08 12 community members and 2 other interested stakeholders Bothwell 5/6/08 3 community members and 4 other interested stakeholders

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At Ellendale there was not the opportunity to conduct the exercise to determine the benefits and risks of each of the options, however there were clear indications that the community supported establishing an MPS. Some submissions were later received from people who had participated in this forum.

In the consultation at Ouse the participants showed a good understanding of the options and identified the benefits and the risks of each option. There was clear support for establishing an MPS with the number of beds varying between 10 and 16.

During the consultations at Ouse some comments were made that if they knew that the GP would not leave if the ODH closed then they might have chosen a different option.

There were significantly less participants at Bothwell, however the majority view was that there were more benefits in the MPS option. One person said that if no beds meant more services that they felt that would be a better option. Another person was concerned about the high focus on aged care commenting that younger people also had health service needs.

Submissions were also called for in the second round of consultations and these were accepted up until the 13th June 2008. Ten submissions were received from community members. Nine submissions supported the retention of the hospital. Some of these submissions identified a preference for an MPS. One submission did not support retaining the hospital and felt that increasing community services was a preferable option.

14.3 IMPACT IF HOSPITAL CLOSED During the consultation process the community highlighted a wide range of issues if the hospital closed. These include:

Older community will not be able to remain in their own community with family and friends; People will not have access to local sub-acute beds; The GP will leave and there will be no pharmacy. The GP practice relies on the ability to admit sub-acute patients at Ouse. New Norfolk is too distant for the GP to service; Loss of an emergency service; Impact on primary industries; Staff and members of the community will leave the district; Housing prices will reduce; The number of children attending the school will decrease; There is a risk that people won’t travel to access primary care and that will put their health at risk; Road and weather conditions (and the high cost of travel) will impact on the ability of community workers to visit people in their homes and also impact on the ability of relatives and friends visiting older people in residential facilities outside of the region; The level of community services will not cater for the needs of older people or the level of support that their carers need; Nearby nursing homes will not be able to accommodate older people from the Central Highlands because of high waiting list numbers; The cost to Government of redeploying and finding alternate work places will be high;

MMT Consultancy Services July 08 - 59 - The town will be left “slowly to die”; Small businesses will be affected in the area; If the residents of the area have to travel long distances for medical reasons they may put it off therefore putting their health at risk; The emotional health and well-being of the community will be affected; Residents in the community would be severely disadvantaged because alternative services would be considerably more remote, making the time and cost to access the services very difficult; Any reduction in service would have a strong negative impact on the surrounding community and that there may well be a need for more services; Total reliance on GP-assist for emergencies would be unsatisfactory; Safety of community care staff cannot be assured; Would remove much-needed step-down potential; No emergency care for tourists/ workers/residents; Likely uneconomic demands on the public health system; and The reliance on community nursing and out-reach services would be inherently unsafe in the Central Highlands where the population is highly dispersed, signage is poor, houses are hard to find and winter conditions make travel unsafe for persons not familiar with the area. At times, areas are isolated for days by snow. These conditions would preclude trips by single nurses/ carers on safety grounds. 14.4 COMMUNITY PERCEPTION OF HOSPITAL In many of the submissions and in the consultations the community described the hospital as a basic health service. The majority of people said that people have a right to basic health services and primary health care when referring to the services provided at the hospital.

FINDING Residential aged care places or hospitals are not basic primary health services. They are at the upper end of the aged care and health care system and are therefore carefully planned by the Australian and State Governments because they are high cost services.

Every Australian has a right to access high level aged care or hospital services when they need it. However these high cost services must be limited on a planning basis so that prevention, early intervention and home care services can be available locally for all.

The community considers that the 24/7 emergency service at the hospital is a critical service that must be maintained.

FINDING There are risks in relying on the ODH as a 24/7 emergency service. It is not safe for a registered nurse to be dealing with emergency conditions with only the support of an enrolled nurse or carer on duty at Ouse, while at the same time being responsible for caring for the inpatients, in areas such as management of medications/intravenous fluids and syringe drivers.

While the staff in the hospital provide reassurance and stabilisation for people who attend, for an emergency calling an ambulance immediately or GP Assist is a safer option. It is acknowledged that ambulance response times need to be improved and a better arrangement needs to be put in place for direct access to GP Assist.

MMT Consultancy Services July 08 - 60 - The community considers that one of the ways to keep the hospital is to increase activity of the hospital beds, however this needs to be provided safely and efficiently and also needs to fit within the overall Tasmanian Health Plan.

FINDING The occupancy rates of the hospital beds have been low. Efforts to retain the hospital by increasing the number of beds/places or offering additional services, such as post-acute care and day surgery would rely on a sustainable and skilled workforce. With the current shortages and instability of the staffing situation a skilled workforce cannot be guaranteed. Increasing beds/places would be a high risk strategy that would continue to threaten the viability of the service.

MMT Consultancy Services July 08 - 61 - 15 FINDINGS An effective health service must have a balance across health prevention, promotion and early intervention services as well as access to secondary and tertiary care.

At the same time an effective aged care system must have a balance across the provision of basic maintenance and support services delivered in the home as well as access to residential aged care.

Funding needs to be carefully planned across all of the areas to ensure that the priority needs of the population can be met, particularly in an environment of limited resources.

The findings of the review are outlined below.

DEMOGRAPHICS The highest number of people in the Central Highlands are in the age range 50-59 years, (n=389) followed by 40-49 years of age (n=349). There is a higher number of children and young people aged 0 to 19 than would normally be expected in a population profile. The highest number of people aged 75 years and over live in Bothwell (n=43), followed by Ellendale (29) and Wayatinah (12).

The greatest concentration of people in the Central Highlands live in Bothwell followed by Ellendale, Hamilton, Gretna, Wayatinah, Ouse and Miena and more people live in the southern part of the Central Highlands.

Statistical analysis indicates a likely small decline in the region’s population through to 2018.

The majority of the patients seen by the GP in Ouse are aged 50-59 years (mirroring the population profile) followed by people aged 60-69 years and 0-9 years. By far the largest numbers of patients seen by the GP in Bothwell are adults.

HEALTH AND AGED CARE SERVICE NEED Service Need Identified by the Community The first community consultations identified a wide range of population need for health and aged care services. More people attended the consultations in Ouse, compared to other areas. There was strong support for retaining the ODH and expanding hospital and aged care services. However, the consultations also identified other health service needs for children, families, young mothers, people with chronic disease and other members of the community.

The vast majority of the community saw more benefits in establishing an MPS.

GP Patient Need A high number of GP patients in the Central Highlands have preventable conditions such as hypertension (high blood pressure), which is a high risk factor for stroke, high cholesterol, which is also a high risk factor for stroke as well as heart disease, Type 2 diabetes and chronic obstructive airways disease.

The GP in Bothwell reported that the population in the northern part of the region have higher rates of diabetes.

MMT Consultancy Services July 08 - 62 - Needs identified by other stakeholders The gaps identified by other stakeholders included:

Training and education for nurses; Services for families, youth and children; In hospital – palliative care, respite; Better supporting people with chronic disease and an increased emphasis on self management; Transport; Immunisation for children and older people; Mental health; Increased Practice Nurses services, particularly for people with chronic conditions; Access to a ‘first aid post’.

Aged Care Service Need The community does not appear to fully understand the process for accessing aged care services for both residential and in-home care.

Many older people receiving their first ACAT assessment are being recommended for high level residential care. This is not early enough as early intervention could potentially delay the need for residential care. The reasons for this need to be further explored.

Additional findings relating to aged care service need are outlined below.

Rehabilitation Services for Older People Older people in the Central Highlands need access to rehabilitation/transition care in a supported environment so that they can return home, thus delaying the need for early entry into residential care.

CURRENT SERVICES PROVIDED IN THE REGION There is no up to date and comprehensive data base in the Central Highlands or the Australian or State Government that identifies all of the services available in the Central Highlands region.

HOSPITAL SERVICES PROVIDED There are a small number of hospital beds in ODH. Occupancy rates and the number of admissions have been low for a considerable time and were even lower when a GP from New Norfolk had admitting rights to the ODH in 2006. In the last two years there has been an increase in admissions for same day procedures.

74% of people who presented to the accident and emergency service were for planned care that did not need to be undertaken at an accident and emergency facility.

QUALITY AND SAFETY Any future delivery model for the Central Highlands must be able to ensure quality of care.

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AMBULANCE SERVICES The number of ambulance carries by volunteer ambulances or ambulances coming into the region do not justify a full paramedic service in the Central Highlands.

There was considerable community concern about ambulance response times. It is imperative that there is a strong system of retrieval (ambulance) for emergency conditions. The response times from New Norfolk need to be improved urgently.

GP ASSIST GP Assist is a free service to rural GPs who choose to use it. It operates from 6.00pm to 8.00am 7 days a week. GPs using the service transfer their phone line directly to GP Assist's 1300 number or they may use it more selectively.

GP Assist is used at the ODH by the nurses as there is no separate telephone line for the GP Practice in Ouse. Separate telephone lines are needed in the hospital so that when people ring their GP after hours the call goes directly to GP Assist. This arrangement will provide quicker access to GP advice, which could be needed in an urgent situation. The availability of GP Assist needs to be promoted in the community.

GP Assist is only available to people who have a GP, although they do take calls from tourists or workers who have accessed the telephone number. The Evaluators are aware that a National Call Centre will be established across Australia within the next year. When this occurs it must be well promoted, particularly to people living in rural communities and people traveling or working temporarily in rural areas.

AGED CARE SERVICES Residential high care places in ODH Due to the long length of stay of a number of residents in the ODH, the Evaluators consider that some residents in the ODH may have been assessed inappropriately for high level residential care and/or if rehabilitation, transition arrangements or alternative safe accommodation was available, such as an independent living unit closer to facilities, this would have been a more appropriate option.

Five of the 11 residents came from the northern part of the Central Highlands region, indicating that older people living across the Central Highlands are accessing the residential places.

The Australian Government aged care planning and allocation benchmark is based on an allocation of 44 high care, 44 low care and 25 community care places per 1,000 people aged 70 years or more. Applying the benchmark to the population aged 70 years or more for the Central Highlands population is notional as the formula is based on the number of older Australians aged 70+ per 1000 of the population within an aged care planning region.

MMT Consultancy Services July 08 - 64 - The ODH has had 6 residential places and there are 3 community packages, therefore if the community needs access to approximately 22 aged care places in the Southern region, other older people must be accessing residential care outside of the Central Highlands.

Community aged care packages Additional CACPs are needed for the southern planning region. The community and service providers in the region require more information about the role of the ACAT and that it offers entry to community care.

The option of home care needs to be further promoted across the region.

Home and community care program Older people in the region are receiving less HACC services compared to other older Tasmanians.

More HACC services are required across the Central Highlands and the services need to be further promoted to the community.

OTHER SERVICES General Practice The GP facilities in Ouse require expansion to operate more effectively.

The Evaluators consider that Group Practice, with the support of Practice Nurses is more sustainable in the longer term to balance life/work and support contemporary practice for individual GPs.

Regional Health Service The Regional Health Service based at Ash Cottage should be integrated into the future service delivery model for the Central Highlands.

Carer Support and Respite There are significant gaps in support and respite for carers across the Central Highlands.

Transport Transport is a major issue for the community. The Evaluators highly support the DHHS initiative to improve access to transport as long the guidelines are flexible enough to incorporate the needs of the community.

Attracting Funding Regardless of the final option, the Evaluators have observed that there is a need for a dedicated person to provide the leadership required to build networks, create partnerships and attract increased funding to the region for improved access to health and aged care services.

Available Facilities There are good facilities in the region, such as the Ouse Golf Club premises and the Miena Community Hall that could be better utilised in the future.

MMT Consultancy Services July 08 - 65 - There are five units next to the ODH that could be upgraded (at a cost of up to $66,500) for use as independent living units for older people.

CURRENT STAFFING Tasmania is experiencing significant difficulties in recruiting and retaining nurses, particularly in rural and remote areas and it is expected that this will be a long term problem. If the hospital remains open many of the issues relating to managing the roster will certainly continue.

COST OF HOSPITAL BEDS AND AGED CARE PLACES Cost It cost approximately $1.3m to run the Ouse District Hospital in 2006/07, including income of $295,000 received from the Australian Government and resident fees for the 6 aged care beds (this does not cover the actual cost). Other income of $52,000 was received in inpatient fees for the 4 hospital beds. The State contribution was $1.145. There was a budget overrun of approximately $135,000, which was mainly due to employing agency staff to address the nursing workforce issues.

In 2006/07 on average, each bed cost $128,000 net to operate (excluding the overrun and regardless of whether the bed was being utilised). The DHHS is subsidising the costs of the aged care places considerably.

Inpatient facilities such as those provided at ODH are basically inefficient because of their size. Making comparisons with facilities of equal size is comparing degrees of in-efficiency.

Opportunity Cost The real cost of providing inpatient services for a very small number of people is not providing community care and preventive services for a substantially larger number of other people.

The Ouse Hospital is inefficient because of its diseconomies of scale, and the scale of operations directly threatens the safety of patient care.

COMMUNITY PERCEPTION OF HOSPITAL In many of the submissions and in the consultations the community described the hospital as a basic health service. The majority of people said that people have a right to basic health services and primary health care when referring to the services provided at the hospital.

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The community considers that the 24/7 emergency service at the hospital is a critical service that must be maintained, however there are risks in relying on the ODH as a 24/7 emergency service. It is not safe for a registered nurse to be dealing with emergency conditions with only the support of an enrolled nurse or carer on duty at the hospital, while at the same time being responsible for caring for the inpatients and residents, who may require observation for medications/intravenous fluids and syringe drivers or assistance with toileting.

The occupancy rates of the hospital beds have been low. Efforts to retain the hospital by increasing beds or offering additional services, such as post-acute care and day surgery would rely on a sustainable and skilled workforce. With the current shortages and instability of the staffing situation a skilled workforce cannot be guaranteed. Increasing beds/places would be a high risk strategy that would continue to threaten the viability of the service.

MMT Consultancy Services July 08 - 67 - 16 OPTIONS & VIABILITY OF A MULTIPURPOSE SERVICE

16.1 OPTIONS IDENTIFIED Prior to the second consultation the Evaluators identified a range of options as follows:

1. No change – this is an appropriate option because an objective evaluation may find there no need to change that is, keep the status quo.

2. Create an MPS Have no beds – not an option as at least one residential aged care place must be in the model. Transfer the beds temporarily to another provider for Central Highlands use and in the interim attract further places for the ODH to assist the ODH to become viable. – this option was discussed with some aged care providers in Tasmania and it was found that it would not attract provider support because they would need to invest funding to build the beds, with no long term guarantee of the use. Transfer the beds permanently to another provider for Central Highlands use – this was not considered an option because the funding would be transferred out of the region permanently and it would have no community support. Operate a small number of beds in Ouse (between 1 and 10). Operate a larger number of beds in Ouse (between 10 and 20).

3. No longer provide beds in the region and keep the funding to provide primary and community care services.

The Evaluators included the options in bold outlined above in the Consultation Booklet.

16.2 APPRAISAL OF THE MPS The Evaluators have been tasked to assess the viability of an MPS in the first instance before considering alternative means by which services could be improved if the MPS option is not considered viable. However, there are a number of areas that the Evaluators consider need to be addressed regardless of what option is recommended (such as improved ambulance response times). These are outlined in the findings in Section 15.

The objectives of an MPS are to:

Improve access to a mix of services; Enable more innovative, flexible and integrated service delivery; Enable flexible use of funding; Improve quality of care; and Improve cost effectiveness and long tem viability.

BENEFITS AND RISKS OF MPS OPTION Outlined below is a table that shows the major benefits identified by the community in an MPS model and the risks identified by the Evaluators.

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Table 30: Benefits and Risks of the MPS option

BENEFITS FROM COMMUNITY RISKS FROM EVALUATORS PERSPECTIVE PERSPECTIVE Establishing an MPS will secure the With the current workforce issues and the small hospital beds and aged care places in number of beds/places and staff these services will not the future. be guaranteed in the future. The uncertainty of beds/places in the region will continue (if not in 12 months then in the medium term). The insecurity of employment in the hospital for staff will continue. The MPS will provide flexible bed use. The MPS will enable the beds/places to be used flexibly, but not for community services as the staff establishment must remain. More funding would be needed. There is a national and international trend to develop hospital avoidance models that will reduce the demand for hospital care. Day surgery and new technologies have already reduced the demand for hospital care. The focus on reducing demand will certainly continue in the future. Increasing the use of the beds for step- The occupancy rates of the hospital beds have been down care and other short term care low and there is a low demand for hospital beds. will increase occupancy and therefore Efforts to retain the hospital by increasing beds or the long term viability of the hospital. offering additional services, such as post-acute care and day surgery would rely on a sustainable and skilled workforce. With the current and future regional and state supply of nurses this supply cannot be guaranteed.

Would retain the GP and pharmacy This is a decision for the GP to make. Other doctors have declined offers to work in Tasmania because they do not want to be responsible for providing medical services in a small rural hospital. The delivery of hospital beds relies on the availability of a GP and if the GP left for any reason at all it would put the future of the hospital at risk. This is a further indication that the viability of retaining beds at the ODH is fragile Older people will be able to remain in There is no certainty that bed closures will not occur the community again in the future because of staffing issues. It is more likely that the beds/places will be unstable in the future because of workforce shortages. Staff stability will be assured. Other MPS’ are experiencing workforce shortages. Any option including beds will mean that staff stability will not be assured. Staff would be fully utilised with a 16 A 16 bed MPS would mean additional capital costs and bed MPS. additional recurrent funding. Putting that aside, recruiting and retaining staff will still be an issue. An MPS is not just about beds it is about the provision of a range of services to best meet the needs of the community. This will require staff to work flexibly within and outside of a hospital setting. The majority of staff in the ODH have indicated that they do not want to work in the community and prefer to work in a hospital environment. This would create problems with allocating staff to deliver appropriate MPS services.

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BENEFITS FROM COMMUNITY RISKS FROM EVALUATORS PERSPECTIVE PERSPECTIVE Most services now exist There are significant gaps in health services for people living in the Central Highlands. For example: For older people there are gaps in low and high care packages, transition care, rehabilitation, home and community care services and home monitoring. There is very little support for carers, including respite. There are gaps in allied health services. There are gaps in transport options. There are gaps in services for children and young people. There are gaps in supporting new mothers and families. There are gaps in supporting people with chronic conditions. There are gaps in health promotion, preventative services and health assessments undertaken in the home.

The hospital and medical facilities at It is recognised that hospitals in rural areas provide residents Ouse contribute to the emotional well with a sense of security and community. being of the community and this has However, under the MPS option the long term security of the value to the future health of all hospital is not assured. residents.

APPLYING THE CRITERIA TO THE MPS OPTION The table below applies the criteria outlined in the Consultation Booklet. Table 31: Application of Criteria to MPS option

CRITERIA MPS OPTION Meet the priority needs identified by Hospital and residential aged care beds will be able to be the community. provided, subject to the high risks of being able to sustain the service. Additional funding will be required to meet other priority needs identified by the community. Contribute to a robust health and Uncertainty of the continuation of the hospital will continue aged care service that will continue because of workforce shortages. well into the future. Enable a comprehensive and Without additional funding the MPS will only provide hospital integrated range of services that will beds, residential aged care places and only a small amount of meet the changing health and aged community services. care needs of the community. Ensure a quality service for the The risk of staff shortages for the hospital puts the quality of community. services for the inpatients and residents at risk. Enable the recruitment of a Retaining the hospital will not guarantee a sustainable skilled sustainable skilled workforce in the workforce. area to ensure safety of client care. The distance from urban centres will place further pressure on attracting staff to the region. Rely on the provision of a local The provision of hospital beds, relies on a medical service in medical service in the longer term. the longer term, which cannot be guaranteed. Maximise the resources and the Resources would continue to be allocated to a small number of facilities that are available in the people in the population. region. Provide the opportunity to attract Yes, through the proposal to employ a Business Development new funding to the region. Project Officer. Although there will be a low service base that the Project Officer will be starting from.

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CRITERIA MPS OPTION Support the principles of the The MPS option does not meet the principles relating to Tasmanian Health Plan. sustainability, acceptable cost, appropriateness, safety, or service integration. The services provided by Tasmania’s primary health The option is also not focussed on health promotion, illness services should be: prevention or early intervention. • accessible as close as possible to where people live provided they can be provided safely, effectively and at an acceptable cost; • appropriate to the community’s needs; • client and family focused; • designed for sustainability; • integrated with the other elements of the health service system; • focused on health promotion, illness prevention and early intervention; and • delivered in a culturally appropriate manner.

Where services cannot be The MPS option is focussed on delivering local hospital and delivered safely, effectively and at residential aged care services. It cannot be guaranteed that an acceptable cost from within these will be able to be provided safely, effectively or at an local communities, access to acceptable cost in the future. services should be facilitated through service coordination, the provision of outreach services from an external base, the use of technology, transport assistance and other appropriate community support.

The Evaluators agree that the Central Highlands community require access to hospital and residential aged care and acknowledge that there is a high level of support in the community for retention of the ODH.

The Evaluators do not agree that ODH services are efficient. On the contrary, inpatient facilities such as those provided at ODH are inefficient for no other reason but their size. Making comparisons with facilities of equal size is comparing degrees of in-efficiency. The real cost of providing inpatient services for a very small number of people in ODH is not providing community care and preventive services for a substantially larger number of people in the community.

This economic assessment alone is sufficient to cause deep concern about the way the community’s scarce resources are being used. However, for the Evaluators this was not the key issue. The Evaluators ultimately came to their conclusion because of the unavoidable threat to patient safety that is intrinsic to this type of facility.

It is on the basis that an MPS must operate at least one residential aged care place that the Evaluators have reached the conclusion that an MPS is not a viable solution to meeting the health and aged care needs of the community in the future.

MMT Consultancy Services July 08 - 71 - 17 SERVICE IMPROVEMENT The requirement that an MPS must include at least one residential aged care place means that the community cannot access other benefits of an MPS, such as the flexible use of funding to meet the changing needs of the community.

It is the Evaluators’ opinion that the MPS model needs to be reviewed. In an environment where many hospital sites are closing across Australia there is a need for a new flexible approach in the way services are delivered in rural and remote areas, that does not rely on the provision of 24/7 care in a facility.

Services cannot be planned within small municipalities, they must be planned on a regional basis with established “hubs” for health service provision in more populated areas to provide a greater opportunity to attract and retain a skilled workforce. Planning must take into account where people usually travel for basic services, such as shopping and banking and address transport issues.

The Evaluators were asked to identify alternative means by which health and aged care services could be improved if it was not considered that an MPS was viable.

There are a range of factors that will need to be considered in offering a service that does not include beds or residential places. Many of these were highlighted by the community and they are listed in Section 14.3. The Evaluators acknowledge the validity of many of these arguments.

The Australian and State Governments are strongly encouraged to work with the community and local providers to identify strategies to respond to the issues the community has identified.

Service improvement for the Central Highlands needs to be planned on the basis of the hub and spoke model taking into consideration where people usually travel.

Within the Central Highlands people in the south generally travel towards Hobart, however people in the north tend to go to Deloraine, outside of the Central Highlands. The following service response has been identified, however it should be noted that the services required may not necessarily be delivered from within the region.

Increasing the range and quantity of services in the region will be a slow and competitive process as the Central Highlands is starting from a low community service funding base. It will take considerable time to build a robust system that will meet the health and aged care needs of all local population groups.

MMT Consultancy Services July 08 - 72 - 17.1 SUMMARY OF SERVICE NEED Outlined below is a summary of service need identified by the Evaluators giving consideration to all of the information collected during this review.

Better access to information on available services as well as health promotion; Increased services for older people, particularly in the home and for social support; Increased housing options that provide more support for older people as they become frail; An increased focus on transition programs for rehabilitation that enable the population, including older people to return home safely; Early assessment for older people to access home care and repeat assessments as their health and aged care needs change; An increased focus on supporting carers; Home-based palliative care; Services for children and families, particularly young mothers; Access to general practitioners services; A focus on preventing chronic disease, particularly for the large adult population; An increased focus on assisting people to self manage chronic disease; Support for young people; Increased access to allied health; Timely access to medical advice and emergency retrieval; and Access to hospital, palliative care and residential aged care services.

17.2 SERVICE IMPROVEMENT Outlined below are some identified areas to meet the health and aged care needs of the community in the future.

Funding Bring together the funding from HACC and CACPs under the management of the “mini hub” and identify any other funding that could be managed in the region (not funding for visiting services).

MMT Consultancy Services July 08 - 73 - Contract a Business Development Project Officer with one-off funding for four years to attract more funding to the region. Overtime the aim should be for this position to become self-sustainable. Establish a system that identifies all of the health and aged care services available in the Central Highlands region to assist to identify gaps, improve planning and to promote services.

Transport Transport is a major issue for the community and access to health and aged care services must be improved as a priority.

ACAT Assessment Better promote the role of the ACAT as early intervention could potentially delay the need for residential care.

Carers Increase the level of access to current services that support carers (of all ages) and/or develop new carer support programs including respite and carer support groups.

Chronic disease

MMT Consultancy Services July 08 - 74 - There needs to be an increased focus on the prevention and self- management of chronic disease, including increased diabetes education and support groups across the region.

Families, children and young people Develop programs that will support families, including young mothers. Increase support for young people.

Wellness Identify ways to increase access to services and activities that focus on wellness eg yoga and counselling.

Allied Health Identify ways to increase access to allied health services through partnerships, regional arrangements and improved transport.

MMT Consultancy Services July 08 - 75 - 18 ATTACHMENT 1 – STAKEHOLDERS CONSULTED The Consultants held face to face and telephone interviews with the following people.

NAME POSITION ORGANISATION Staff Various positions Ouse District Hospital Pip Leedham Director, Primary Health Department of Health and Services Human Services Gary Armstrong Former District Manager Department of Health and (ARCH South) Human Services Skye Fraser Primary Health Coordinator Department of Health and South, Primary Health Human Services Services Dr Renier Swart Rural Medical Practitioner, Department of Health and Ouse District Hospital Human Services Susan Rasmussen Clinical Nurse Educator, Department of Health and Primary Health Services Human Services Colleen Smith A/Director of Nursing, Department of Health and Ouse District Hospital Human Services Grant Lennox Chief Executive Officer, Department of Health and Tasmanian Ambulance Human Services Service Richard McKercher Chief Executive Officer General Practice South (Julie Dunbabin) Andrew Power Chief Executive Officer Corumbene Aged Care Facility Cliff Partridge Chief Executive Officer Aged Care Deloraine Lorraine Stott Director of Care Toosey Aged and Community Care Chris Bodger Director of Nursing, Department of Health and (Julie Cooper & Julie Midlands Multi-Purpose Human Services Bradford) Centre Julie Cooper Coordinator, Midlands Department of Health and Multi-Purpose Centre Human Services Tracey Turale Primary Health Care Department of Health and Coordinator, Central Human Services Highlands Marina Campbell Manager, Campbell Town Department of Health and Multi-Purpose Service Human Services Anthony Speed A/g State Manager Department of Health and Ageing Catherine Brown Assistant Manager, Health Department of Health and Programs Ageing Drew Beswick A/g Assistant Manager, Department of Health and Aged and Community Care Ageing Peter Barns Chief Executive Officer General Practice Workforce (Lawrie Donaldson) Kate Vallance Project Manager, Non- Department of Health and

MMT Consultancy Services July 08 - 76 - Emergency Transport Human Services Janet Carty Manager, Home and Department of Health and Community Care (HACC) Human Services Dr Greg Booth General Practitioner Bothwell Medical Centre Darren Mathewson Chief Executive Officer Aged and Community Services Tasmania Melanie Gibbons Organiser (South) Australian Nursing Federation Deirdre Flint Mayor Central Highlands Council Dr Rob Paton Anaesthetist, Hobart Ouse community member Tim Jacobson Assistant Secretary Health and Community Services Union (HACSU) Vianne Brain Senior Citizens Central Highlands Tanya Lovell Volunteer Ambulance Central Highlands Paul Horne Field Officer Midlands Fire Central Highlands Brigade Bob Lovell Constable Hamilton Police Station Stephen Timmins Constable Miena Police Station Peter Birchall Constable Bothwell Police Station Faye Davies Volunteer Tasmanian Ambulance Service; Senior Citizens Luncheons Terry Edwards Chief Executive Forest Industries Association of Tasmania Don Ainsworth Administration and Saltas Finance Manager John Jappe Secretary/Treasurer Ouse Country Club Geoff Herbert President Central Highlands Hunting Association Ken Bye President Central Highlands Shack Owners Association John Cleary President Southern Highlands Progress Association Lyn Burke Chairman Centralink (Hamilton) Mary Downie President Go Highlands Inc Barry Chipman State Manager Timber Communities Australia John Eyles Son of resident Ocean Grove Vic Phyl Smithurst Community member Ellendale Bruce Williams Farmers and Graziers

MMT Consultancy Services July 08 - 77 - 19 ATTACHMENT 2 – FIRST COMMUNITY CONSULTATION

The table below shows the number of people in the Central Highlands that attended the 1st consultations.

Location 1st Consultation Ouse 86 community members Bothwell 11 community members and 4 other interested stakeholders Wayatinah 9 community members and 5 other interested stakeholders Miena 7 community members and 6 other interested stakeholders

* Other interested stakeholders included members of the Central Highlands Council and the Medical Services Committee.

Outlined below are the areas of need identified in the four community consultation sessions during the week of the 28th April.

1st CONSULTATIONS OUSE WAYATINAH BOTHWELL MIENA

Aged Care Beds * * Low care * High care * Acute Transition: Hospital to Home * Respite Care * Overnight * * In home * General * Day Centre * GP (non specific) * * * GP (full GP service) * * Female GP * Pharmacy * * * Accident and Emergency * Basic first aid * Casualty - Emergency care 24/7 * Medical – After Hours Emergency * 24 Hour Medical Coverage at Ouse * Hospital Ambulance * *

MMT Consultancy Services July 08 - 78 - 1st CONSULTATIONS OUSE WAYATINAH BOTHWELL MIENA Local Ambulance * Paramedics * More hospital beds * Post operative care * Step Down Care * Palliative care * Sub acute; retention * hospital local 24/7 * Transition Care – new Mums * Palliative Care in home * Independent Living Units for older * * people near to hospital Transport * * Allied Health Physiotherapy * Dental * * * Optical * * Chiropractor * Psychology * Audiology * Allied health (non specific) * * Visiting Community Nurse * Nurse Practitioner * Mobile Mammogram/X-Ray * Mobile Blood Bank * In home support for elderly & people * * with chronic conditions Personal care * Home Maintenance * Meals on wheels * In home support (non specific) * * Programmes for Elderly * Support – Parenting, Carers, Youth, * DV Access to Information re Equipment * Volunteerism *

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1st CONSULTATIONS OUSE WAYATINAH BOTHWELL MIENA Volunteer ambulance increase * training Increased 0-5 Child and Family * Health Support Network – Single Mothers * Immunisation * Mental Health Services * Self Managed Groups eg Chronic * 24 Hour Care/Advice * Health education in schools * Health Education “Roving” Clinics * Child & youth health services * * Access to Information * Healthy Lifestyles * Carer Support * Occupational Health and Safety * Preventative Services * * Preventative/Post-Incident Care (eg * physio, yoga, counselling, lifestyle support) Establish a local Self-Help Register * eg a good phone, a medico on holidays

Issues/ other comments OUSE WAYATINAH BOTHWELL MIENA Costs to Access (petrol) * * Most use other GP locations outside * of LGA Do we need Ouse Hospital just * because its there. Ouse is not central. * Why not services such as Nurse from * Deloraine – closer. Concept of Ouse as Medical Hub * Overseeing Services Delivered to Outlying Towns such as Miena. Summer Increased Needs with * increased population Mobile/Internet coverage/access * * Transport * * MPS to Include Allied Services * * Additional Costs for Rural People to * Access Services Isolation – Distance – Roads – * * Weather

MMT Consultancy Services July 08 - 80 - Issues/ other comments OUSE WAYATINAH BOTHWELL MIENA Increase beds in Hospital * Insecurity of Unknown * Lack of Local Aged Care Facility * Security of Current Services for Staff * More Beds, More Flexibility * Flexible Beds – Good Idea, Needed *

MMT Consultancy Services July 08 - 81 - 20 ATTACHMENT 3 – CODES FOR TOWNS

SUBURB CODE APSLEY E ARTHURS LAKE N BOTHWELL E BRADYS LAKE W BRONTE LAGOON W BRONTE PARK W DEE LAGOON W DERWENT BRIDGE W ELLENDALE S FENTONBURY S GRETNA S HAMILTON S HOLLOW TREE S INTERLAKEN E LAKE ST CLAIR W MEADOWBANK S MIENA N OSTERLEY SW OUSE S PELHAM S STRICKLAND SW TARRALEAH SW VICTORIA VALLEY SW WAYATINAH SW

MMT Consultancy Services July 08 - 82 - 21 ATTACHMENT 4 – INFORMATION REVIEWED

May 2007 Tasmania’s Health Plan, Primary Health Services Plan, Department of Health and Human Services 2007 Primary Health Services Plan, Community Profile, Central Highlands, Department of Health and Human Services, Tasmania May 2007 Tasmania’s Health Plan – summary, Department of Health and Human Services

April 2008 Central Highlands Community Profile

Oct 2007 Tasmania’s Health Plan, Primary Health Services Plan, Program Implementation Plan 2007- 2010, Department of Health and Human Services

2006 Draft – Rural Hospitals Service Capability Framework Case Studies, Department of Health and Human Services., Tasmania undated Rural Hospitals Service Capability Framework – Ouse site assessment 2007 Central Highlands Services Redevelopment Project, Service Model, Version 1.2, Community Health Services Group, Department of Health and Human Services

Various documents relating to the Aged Care Standards Accreditation for the Ouse Nursing Home Central Highland Service Model Various correspondence relating to attracting sustainable General Practice, nursing services and other issues in rural areas, particularly in Ouse Various papers, reports and correspondence relating to staffing and recruitment at Ouse Various reports and correspondence relating to the Regional Health Service funding from the Department of Health and Ageing 2008 Central Highlands Redevelopment Project, After-hours Emergency Support Model - Options paper (draft)

2007 Central Highlands Integrated Multipurpose Service (CHIMPS) – Medical Services Special Committee of the Central Highlands Council Documents provided by the Medical Special Committee Multipurpose Service Model Submission of original health plan Submissions and comments on health plan implementation Ouse District Hospital Information relating to community input eg articles, letters, handouts Media releases Multipurpose Services: Department of Health and Ageing website Australian Bureau of Statistics Census data 2006 Website for the Ouse District Hospital of the Derwent Valley and Central Highlands Central Highlands Council New Residents Kit Department of Health and Human Service website Financial and activity data from the Department of Health and Human Services Service and aged care information from the Department of Health and Ageing Unidentifiable patient data from Dr Swart and Dr Booth Aged Care Assessment Team, HACC and ambulance data Information from residential aged care providers

MMT Consultancy Services July 08 - 83 - 22 ATTACHMENT 5 – RHS ACTIVITY 2007

Activity Location No. of Priority Health Need Participants Mental Health Week Ouse 17 Mental Health Health & Well being Day Rural Health Week Event Bothwell 250 Physical Activity The ‘Central Highlands Active Chronic Disease Spring Carnival’ involved local Management schools, service clubs, individuals Nutrition and the community. Youth Health Mental Health Positive Ageing Expo Ouse 100 Chronic Disease Management Social Isolation Women Get Active Program Hamilton 10 Physical Activity Mental Health Confidence Café - Women’s Ouse (3) 35 Mental Health Health & Wellbeing Days Social Integration / Relaxation Red Hat Society Bronte Park 15 Mental Health Women’s Group Social Interaction Suicide Prevention Project Central Highlands Total of 212 Mental Health occasions - Youth Health Girls Health & Wellbeing Days Ouse 6

Youth Activities - various Ouse 42 Hobart Mental Health First Aid Courses x 2 Ouse 17

Community Forum on Suicide Ouse 10 Prevention - DHHS Police Citizens & Youth Club Mobile Ouse 40 Activity Centre (MAC Bus) – monthly visits Fly Fishing & Aquaculture Program Ouse 7 Bradys Lake Lake Currawong

Bill Rogers Workshops – Positive Ouse 12 Behavioural Management for Teachers Suicide Awareness & Prevention Gretna 44 Information Sessions Bothwell Ellendale Wayatinah Ouse Tadpoles Parenting Centres & Central Highlands 110 – Includes 1. & Early Childhood Mobile Playgroups (0-5 years) 2. below Development Communities for Children Parent Support (0-5 yrs) Program (FaCSIA)

Parenting Hubs Central Highlands

Playtime Groups Ellendale Gretna Wayatinah Bronte Park Family Fun Days Ellendale 210 Bothwell Community Bus Project Central Highlands Transport

MMT Consultancy Services July 08 - 84 - Activity Location No. of Participants Priority Health Need

Odd Job Squad Central Highlands Centralinc Aged Care Support

Home help & maintenance project Community Volunteering Volunteers

Youth Behaviour Management Ouse District High 15 Mental health Workshop School Life skills Interpersonal Skills Suicide Prevention

Music with Matthew PULSE Youth Health - 10 Social integration (Workshops x 2) Glenorchy Life skills Mental Health Interpersonal Skills

‘Getting to know New Norfolk High New Norfolk High 13 Life skills School’ - orientation School Social integration Interpersonal Skills Mental Health

Embracing Life Workshop Ouse District High 6 Life skills School Mental Health Self Confidence

Women’s Health & Wellbeing Days Ouse (2) 24 Mental Health Ellendale 8 Social Integration / Relaxation Red Hat Society Bronte Park 26 Mental Health Social Interaction Women’s Group Suicide Prevention Project Central Highlands Total of 174 Mental Health Youth Health

Girls Health & Wellbeing Days Ouse 21

Mother & Daughter trip to the Savoy Hobart 18 Baths

Mudlark Theatre Ouse 32

Police Citizens & Youth Club Mobile Ouse 50 Activity Centre (MAC Bus)

Fly Fishing & Aquaculture Program Ouse 7 Lake Areas Bradys Lake Hobart / New Norfolk Girls Wellbeing Group Ouse 6

Suicide Awareness & Prevention Gretna 42 Information Sessions Hamilton Wayatinah Miena Bothwell

MMT Consultancy Services July 08 - 85 -

Activity Location No. of Participants Priority Health Need

Summer Fun Day Hamilton Resource 26 Mental health Centre Social integration Life skills Nutrition Creativity Health & Wellbeing Promotion Harmony Day Cricket Ouse District High 77 Social integration School Life skills Mental Health Health & Wellbeing Promotion

Restorative Practice Community Ouse District High 14 Life skills Conference School Social integration Interpersonal Skills Suicide Prevention

Personal Presentation Day Ash Cottage Ouse 10 Life skills Social integration Mental Health Self Esteem / Self Confidence Hygiene

Health & Wellbeing Session Ash Cottage Ouse 10 Life skills Social integration Mental Health Health Promotion Hygiene / Nutrition

Health & Wellbeing Session Hobart 18 Mental health Social integration Drugs & Alcohol Sexual Health Life skills Suicide Prevention Hygiene Nutrition ‘Rock & Water’ Program Ouse District High 12 Social integration School Life skills Suicide Prevention Self confidence / Resilience

MMT Consultancy Services July 08 - 86 -