Consideration of Urgent Motion
Dr REFSHAUGE (Marrickville - Deputy Premier, Minister for Health, and Minister for Aboriginal Affairs) [3.40]: I move:
Diabetes is an alarming problem in New South Wales. It has a prevalence of between 3 per cent and 4 per cent in the general community, but among older people the figure increases to one in 10. In some Aboriginal and Torres Straight Islander communities the prevalence of people affected is as high as one in five. Two factors make the issue of diabetes an urgent matter for consideration by this House: firstly, between one-quarter and one-half of all people living with diabetes are unaware that they have the condition; and, secondly, if the method of treating diabetes is improved people will be saved from potential blindness, loss of limbs and premature death.
Many of the human tragedies caused by diabetes will be prevented if action is taken now. This House should support the urgent action being taken by the Government to improve the approach to the treatment of diabetes. Part of the problem lies with the lack of coordination of services, with missed opportunities for early intervention, and with preventative education not reaching all affected people. Many excellent diabetes services are available in New South Wales, and individual doctors and facilities across the State are providing quality care and information. Long-term projects have also dealt successfully with particular aspects of diabetes.
However, some people with diabetes still do not have access to appropriate care. That is especially true in rural and remote areas of New South Wales where geographic isolation makes it difficult for people to get the type of regular access to care that they need. Aboriginal communities, who are among those worst affected by diabetes, also face enormous problems gaining access to diabetes services. Diabetes is also prevalent among some groups of people from non-English speaking backgrounds and, again, the people most affected often face barriers to effective education and regular care. The Government proposes to establish integrated diabetes management systems at three pilot sites across New South Wales.
The aim of the pilots is to develop the best and the most effective diabetes management system. Once developed, the system will be implemented throughout New South Wales. The programs will ensure that every person with diabetes has access to education for self-care and monitoring. They will also ensure ongoing clinical care to promote good metabolic control. The programs will involve regular monitoring for signs of complications, and appropriate treatment and follow-up will be arranged. The aim of the Government is to provide every community with access to a spectrum of local, culturally appropriate care. Members of this House owe it to communities they represent to support the program initiated by the Government.
I would like to put into context the harm which arises from diabetes. In the United Kingdom and the United States of America diabetes is the most common cause of blindness in persons between the ages of 16 and 65 years. Although no figures are available, that is almost certainly the case in Australia also. Diabetes is the most common cause of non-traumatic limb amputations. It is a major factor in the rapid expansion in the demand for renal dialysis, and is the second most common reason for enrolment for dialysis and for kidney transplants in Australia. Debilitating and often fatal conditions, such as coronary heart disease and strokes, are exacerbated by diabetes. It is a common cause of impotence, which affects 40 per cent of men with diabetes over the age of 40, and 60 per cent of men with diabetes over the age of 60.
For Aboriginal and Torres Straight Islander people the situation is far worse. Diabetes is one of the leading causes of premature death among adult Aboriginal men. As honourable members know the life expectancy of Aboriginal men is 20 or more years less than their non-Aboriginal counterparts in Australia. Honourable members should make no mistake: diabetes is a tragic disease that can impose an enormous personal cost on an affected individual. For the health system, of course, the cost of not treating diabetes is just as extreme. Everyone in the community will benefit if people with diabetes are assisted to stay healthy.
Many of the complications caused by diabetes which put patients into hospital may be prevented by good metabolic control, early detection and appropriate treatment. Early detection is vital because the worst effects of diabetes are preventable. Blindness caused by diabetes is preventable in 60 per cent to 70 per cent of cases; amputations caused by diabetes are preventable in 50 per cent of cases; and the treatment of diabetes-related hypertension will significantly slow the progress of renal problems. If the new approach has the reach and effectiveness expected by the Government, it has the potential to save the sight of as many as 32 people each year, to halve the number of lower limb amputations, and to help people with diabetes live longer and healthier lives.
Central to the Government's response to diabetes will be the development of a statewide system of integrated management of the disease. The pathology of diabetes cries out for such an approach. In May the Government released the consensus guidelines for the management of insulin-dependent and non-insulin-dependent diabetes. These guidelines were developed in consultation with health care professionals and consumers. Diabetes Australia was instrumental in this work. The consultation process involved in the development of the guidelines also recommended the establishment of projects to implement systems of integrated care and an evaluation of the guidelines.
The New South Wales Government and the Commonwealth Government have responded to the community by agreeing to fund these projects. New South Wales will fund area and district health services, Aboriginal medical services and public health units so that they can work cooperatively tackle the significant problem of diabetes. The Commonwealth Government will fund the divisions of general practice for their work in conjunction with public health units. An amount of $2 million has been committed to this project over the next two years. The Government is also committed to implementing the successful strategies across New South Wales.
I have announced today the development of three pilot sites for the system of integrating diabetes services. They are in western Sydney, the Macleay-Hastings district and the far west of New South Wales. Each of these local projects has been the result of a partnership of general practitioners, other health care providers and people with diabetes in the local area. All three areas have clearly demonstrated populations in need of care. They have all identified clearly improvements that can be made in the integration of services and how those improvements will result in better care. All three areas have significant at-risk populations.
In western Sydney nine groups from non-English speaking backgrounds have been identified as being at risk and strategies aimed at each individual group will be established. All three areas have significant Aboriginal communities. The support of the local Aboriginal community-controlled medical services has been vital to successfully establishing each of the projects. That support will be even more important in the implementation of the services. This is another sign of the success of the partnership between the Government and Aboriginal community-controlled medical services in initiating, early in the Government's term of office, the delivery of health outcomes for Aboriginal people. Of course, this is the only way to produce culturally appropriate health care strategies.
To achieve real gains in the treatment of non-insulin-dependent diabetes we must change lifestyles, and lifestyle change cannot be imposed from above. Without the full cooperation of local Aboriginal communities programs will not succeed. The reverse side of the coin is the remarkable success which can be achieved by working in partnership with the community. Diabetes prevention and treatment are a priority for this Government. We are meeting our commitment to people with diabetes by working with them and health professionals to build better services. Part of the commitment is the development of integrated care. The Government will play its part in building a strategy which will ensure that every person in this State has access to the care he or she needs. I hope members of this House will support the Government in this initiative, one we hope will be replicated throughout New South Wales and further afield as successes are proven.
Mrs SKINNER (North Shore) [3.50]: The Opposition also notes as a matter of urgency the prevalence of diabetes in New South Wales and is concerned about the number of cases of undiagnosed diabetes. I have personal experience with this as one of my staff members is married to a man who has had mature-age-onset diabetes recently diagnosed. I am very happy to say that with proper care he is able to control the condition without medication but simply by changing his diet and looking after himself a little better. It is encouraging that such practices can be effective without medication. I know of the serious consequences of diabetes, particularly blindness, amputation, renal failure and so on which the Minister mentioned.
However, I wish to comment on the way in which the Minister has addressed the matter to date. Because of the great concentration on reducing hospital waiting lists, money has been diverted for this purpose throughout New South Wales. I have said on a number of occasions that I am getting feedback from hospitals, particularly those in country New South Wales, that they have insufficient money to meet the waiting list reduction program and that they are having to divert money away from important programs to top up the money required for the waiting list reduction program. This means the system is being bled dry. In some areas community health and preventive programs such as those for diabetes are being cut. Because the Premier said that regions would not be funded unless the monthly targets were met there is enormous political pressure on hospitals to meet the targets. Money is being bled from much-needed clinical services and community health services which are involved in detection and treatment of diabetes.
The Minister for Health abolished the health promotion unit, which would have had a very important role in alerting the population to the necessity of being watchful in regard to diabetes, particularly mature-age-onset diabetes. It is a shame that the health promotion unit is not around to assist the Minister in getting the information out to the world. The Minister mentioned renal dialysis. On a number of occasions I have been approached by patients and hospitals concerned about reductions in renal dialysis services. The matter was first brought to my attention by the director of the renal unit at Royal North Shore Hospital, which I consider to be my local hospital. He was disturbed that lack of funding prevented his accepting new patients, particularly as expensive dialysis equipment was still in boxes because of insufficient funds to employ staff to operate it. A similar situation applies in other areas, but renal dialysis is an essential component of treating some people with diabetes and that is why I have raised it in this debate.
The same doctor raised his concern about funding cuts for home dialysis. Given the push to increase home dialysis rather than having patients travel to hospital for treatment when they are obviously extremely sick, the cuts are extraordinary. If anyone wishes to see letters from the doctor they are available. I have already raised the matter with the media. I would be happy to provide the letters to the Minister. He does not know of the specific instances. Hospitals in the Hunter have told dialysis patients who have travelled extensive distances while very ill to receive treatment at John Hunter Hospital that their regular appointments could not be kept and they would have to travel to Sydney to receive treatment. It is all very well to say that dialysis is an important aspect of care of diabetes patients - the Opposition agrees - but the treatment must be provided where it is needed.
The veterans, who until recently were covered by the Commonwealth, have had their treatment transferred to the State system, and insufficient care has been taken to ensure that their treatment has been maintained through home nursing. I understand that many veterans cannot manage home dialysis because they live alone. They now have to be treated in hospital, often after having to travel long distances. The director of the North Shore unit told me that these very ill people have to travel long distances three times a week for treatment, because dialysis is not a matter of choice; it is a matter of essential care. The Minister referred to the need to identify people at risk, particularly in the western Sydney area. I remind the Minister of a patient identified as at risk who was referred to at question time today. The Minister was faxed a letter by Dr Roberta Chow on 27 October this year. The doctor had written to the Minister previously on the matter but still has received no response. The letter states:
That this House notes as a matter of urgency the alarming prevalence of diabetes in New South Wales which is causing ill effects such as blindness, loss of extremities and premature death, and supports the Carr Government's decision to implement integrated care projects to improve treatment for people with diabetes.
I agree with the Minister that it is extremely important to identify people who are at risk. Obviously this insulin-dependent diabetic patient is at risk. Her doctor feels so concerned for her welfare that she faxed the letter to the Minister on 27 October. Today is 14 November and the doctor has not received a reply from the Minister. The Minister's attitude is hypocritical and two faced. If the Minister is serious about giving priority to diabetes patients he should respond to such letters written in great frustration and make sure that money is not diverted from important clinical services such as those providing care for diabetic patients to the waiting list reduction program. He has admitted in private conversations - obviously, they are not so private now - with health carers that he has to focus on the waiting list reduction program because his political neck is at stake.
The Minister is failing on the waiting list promise. Everyone has seen the different ways he is fudging the figures, including excluding people awaiting certain procedures. On the John Laws program the other day it was claimed that there was a telephonic instruction to hospitals that patients requiring treatment in 1996 are not to be on the computerised waiting list. So the Opposition cannot get access to the figures when it uses freedom of information provisions to get the statistics. I commend to honourable members the speech John Laws made a few weeks ago on radio station 2UE. I have circulated several copies of his speech, but I shall ensure that all honourable members receive a copy. If the Minister is serious about diabetes patients getting the treatment they deserve, he will
make sure that the money that is being diverted to save his political skin will be used to assist in the diagnosis of diabetes and to put into place preventive programs and, where necessary, hospital treatment.
Ms HARRISON (Parramatta - Minister for Sport and Recreation) [4.00]: The evidence is compelling that programs must be initiated to combat the avoidable illnesses and injuries resulting from diabetes. While many existing services adequately cope with the problems of diabetes sufferers, many others have fallen through the cracks. Those most at risk of suffering an avoidable diabetes-related illness are those from non-English speaking backgrounds, those living in remote or rural areas, and Aboriginal people. Clearly, diabetes services are not being used either because they are not readily accessible or because people are unaware they are suffering from diabetes. This issue needs urgent attention. One area which needs special attention is Sydney's greater west. Seven years of Liberal mismanagement and indiscriminate budget cuts have had a serious and negative impact on health services in Sydney's greater west.
Mr Phillips: On a point of order: on occasions leniency is shown in this House with regard to members reading speeches. The standing orders provide that speeches must be the member's own words. Members should be allowed to refer to notes. Ministers, of course, should deliver second reading speeches from prepared texts. However, when members speak to a motion such as this, their words should come from the heart, and not from a text prepared by someone else.
Mr SPEAKER: Order! I am sure the Minister for Sport and Recreation is only referring to copious notes.
Ms HARRISON: The Carr Government has acted quickly to redress the imbalance caused by the Greiner and Fahey governments. In recognition of the growing population pressures and demands in Sydney's greater west, badly needed health resources have been redirected to that area. The moves to cut back on the incidence of diabetes-related illnesses will especially target Sydney's greater west. In line with the initiatives on diabetes formulated by the New South Wales and Commonwealth governments, a network of integrated services for diabetes sufferers is being developed in Sydney's greater west. The aim of integrated care is to ensure that everyone suffering from diabetes has access to education for self-care, routine care to promote good diabetes control, and regular screenings for signs of complications arising from diabetes-related conditions.
Mr Phillips: On a point of order: I am sure the Minister is an excellent speaker. I would like an assurance that this speech is her own work. If it is not, she is clearly flouting the standing orders of this House.
Mr SPEAKER: Order! The Deputy Leader of the Opposition should understand that it is not the responsibility of the Chair to determine the authenticity of comments of members or whether someone else has written the speeches that they deliver.
Ms HARRISON: The further enhancement of integrated care services will result in many of the illnesses associated with diabetes being successfully treated. In line with these initiatives, the potential is available to dramatically reduce the incidence of diabetes-related blindness and lower limb amputations, and to extend the life expectancy and health status of diabetics. Let me outline some of the initiatives the Government has launched to establish an integrated network of diabetes services in Sydney's west. Recent in-patient audits at Westmead Hospital have revealed a 10 per cent prevalence of diabetes in the hospital population and a 15.6 per cent prevalence of diabetes in patients attending the cardiac rehabilitation service. An integrated service in western Sydney is clearly needed. The provision of integrated services for diabetics forms the basis of the western Sydney diabetes services plan for 1994 to 1997. The plan seeks to enhance services for diabetics at all levels of service delivery.
Mr Phillips: On a point of order: I presume the continuous reading of a speech that was obviously prepared in the office of the Minister for Health means that members can read speeches, regardless of who prepared them, rather than work from notes and speak from the heart. No-one complains about members referring to notes. However, the standing orders do not allow members to read straight from text.
Mr SPEAKER: Order! The Deputy Leader of the Opposition states the standing orders correctly. However, I am not certain that the Minister is reading directly from text. In any event, the Minister's time for speaking has expired.
Mr PHILLIPS (Miranda - Deputy Leader of the Opposition) [4.05]: The treatment of diabetes is a serious issue. If diabetes has not already affected family members, friends or relatives of most members of this House, it is likely that it will in the future. I understand that a former member of this House, Terry Sheahan, is the president of the National Diabetes Association. He left this place and was surprised to learn that he had acquired a lifestyle disease called late-onset diabetes, a disease that hits people fairly quickly. He is now championing that cause in society and should be commended for bringing the attention of the community to that lifestyle disease. One of the strong arguments I have against the current Government's health policy is the total pre-occupation with volume treatment - the focus on throughput, casemix funding, and on maximising the number of people treated.
In what is supposed to be an urgency motion the Minister for Health talked about integrated management and treatment of people with diabetes. The treatment of diabetes certainly needs to be improved, but the most important thing about diabetes is that it is preventable. Diabetes is largely a lifestyle disease that can be controlled by diet and exercise. Honourable members should clearly understand that neglecting diet and health and neglecting to exercise regularly sends the risk of contracting late-onset diabetes through the roof. Neglecting to have regular blood tests puts people at massive risk of blindness, heart disease and loss of limbs later in life. Diabetes is one of the big issues confronting the health system today.
I was absolutely staggered when the health promotion unit of the Department of Health and the fit 2000 program, which was to be linked with the Olympic Games, were scrapped. Those programs were about investing a small amount of health funding on keeping people well and out of hospital. The community has still not come to grips with the fact that Australians are admitted to hospital 20 per cent more than people in other nations. Australians undergo more operations than people in other nations; they take more drugs and visit doctors more often. The health system obviously has to address the problem of keeping an ageing population well and out of hospital. People do not benefit from living longer if they do not enjoy a good quality of life, and they will not enjoy a good quality of life if they contract late-onset diabetes. The Minister should concentrate on investment in significant health promotion programs to prevent ill health. In the past seven months the Minister has not said one word about that. There have been no new initiatives to deal with tobacco smoking. The Minister has walked away from that problem. The Opposition wants more action to be taken in relation to that and other issues.
Treatment was also referred to. Accident and emergency units treat people with diabetes all the time, yet today when the shadow minister expressed concern for those who were being turned away, the Minister's response was, "Well, I am only the Minister, I am not really responsible. You had better talk to the complaints unit. I have this magic casemix funding system which is increasing throughput and numbers". That is what was wrong with the health system for decades. It concentrated on throughput. The health problems of people in this country will never be solved if more people are made sick. The health system should be about making people well and keeping them out of hospitals and institutions. I appeal to the Minister to tackle the issue of diabetes through better education programs rather than just integrated management programs.
Mr BECKROGE (Broken Hill) [4.10]: It is important that the Parliament and the people of New South Wales understand the Government's program of integrated management of diabetes care, a program on which the Government should be congratulated. It aims to tackle the treatment of diabetes head on and to educate those who suffer from the disease. The Deputy Leader of the Opposition spoke about the late onset of diabetes and in this regard referred to my good friend and colleague Terry Sheahan. My electorate, which is in the far west of the State, extends for great distances but is populated by few people. Hospitals in this region of the State are struggling to deliver services. In recent times rural health units at Dubbo and Broken Hill were set up, and I look forward to those units playing a vital role in this pilot scheme, which is also being conducted in the Macleay-Hastings region, in western Sydney and in the far west. Any project the objective of which is to try to make appropriate health care more accessible across New South Wales should be applauded. It is for that reason that I have decided to speak today in this debate.
Doctors in my electorate have a strong commitment to the success of this important project. The outback division of general practice and the Barrier division of general practice are closely involved in setting the direction and providing delivery of the service. General practitioners, as we all know, are primary caregivers. They look after the basic health care needs of the community and are under extremely constant pressure. The project is a big challenge for general practitioners in the far west. I am pleased that additional funding has been made available by the Commonwealth to enable general practitioners to participate in this pilot project. Diabetes is a lifestyle problem. Many of my friends who have been - for want of a better term - good drinkers over the years, have developed diabetes in their later years. We call it "sugar". People with sugar are put out of action. They are put on either insulin or non-insulin programs. Diabetes often occurs late in life. Where I come from that it happens is taken for granted. The promotion of this pilot project will educate people to moderate their lifestyles to ward off the late onset of diabetes. It is important to get the message across to as many people as possible. I hope the Royal Flying Doctor Service and the rural health units at both Dubbo and Broken Hill are closely associated with the project.
Diabetes affects not only members of the Caucasian population; in rural river towns a high proportion of Aboriginal people contract diabetes. A recent audit of non-infectious diseases in Bourke and Brewarrina found that 30 per cent of the adult Aboriginal population had diabetes or impaired glucose tolerance. Outreach diabetes clinics in the Orana district reveal that 58 per cent of Aboriginal people with diabetes had poor diabetes control. More than one-third of patients had renal disease and one in five had significant retinopathy, a condition that can lead to blindness. Such frightening figures should be warning to us all. We should not be proud of a health system that does not attack the basic problems that face people today. I totally support this motion.
Mr REFSHAUGE (Marrickville - Deputy Premier, Minister for Health, and Minister for Aboriginal Affairs [4.15], in reply: I thank the Minister for Sport and Recreation and the honourable member for Broken Hill for their supportive comments and for their understanding of the issues regarding diabetes, particularly in their local areas. I thank also the honourable member for North Shore for her words of support. Unfortunately, however, opposition members have a few misconceptions, and I believe it is important that they be put right. The first misconception is that the Carr Government has abolished the health promotions unit. That is not true. What we have done is get rid of Richard McKinnon and his $11,000-a-month waste of space. The former Government was spending its health promotion money on a public consultant trying to sell a dopey political message, that the Fahey Government was doing well. We got rid of him, and we have maintained health promotion.
I know the Opposition health spokesperson is finding it difficult to grapple with her responsibilities. She must realise that it will take her some months, if not years, to learn her job. Perhaps if she started acknowledging some of the truths rather than spreading untruths, it would do her some good. The Government has not abolished health promotion. Rather, it has been expanded and upgraded. Another misconception of the Opposition is that the Government is not interested in prevention. To the contrary. In debate in this House I have spoken about the importance of prevention as an integral part of managing diabetes. Obviously, the Deputy Leader of the Opposition wanted an axe to grind to justify his failure as a health Minister. As he pointed out, prevention is an important part of looking at the whole issue of diabetes, but it does not detract from the fact that we need much better treatment of the disease.
The issues raised by Diabetes Australia in National Diabetes Week relate to treatment and better integration of treatment. It is important that the many people with undetected diabetes are diagnosed and provided with effective treatment. It is well known that with better control of diabetes, patients' blood glucose levels are maintained and they are less likely to suffer retinopathy, neuropathy, micro vessel problems - which lead to major problems with kidney - and micro profusion in the lower limbs and the vital organs. The treatment is incredibly important. The Deputy Leader of the Opposition said that those who have diabetes live a wretched life.
Mrs Skinner: He said it is a lifestyle disease.
Mr REFSHAUGE: He said it is a wretched life. That is not the appropriate message to the many thousands of people who have diabetes. Treatment can control blood sugar and delay, if not stop, the development of neuropathy, retinopathy and vascular problems. The former Minister also claimed that Fit 2000 was suddenly a fantastic program. It could have been a fantastic program had he provided money for it, but he did not provide one red cent for the Fit 2000 program. He provided a telephone line on which people were told, "Sorry, there's no money." It was an absolute disaster! It may be that the former Minister liked to run a health promotion scheme whereby people would make submissions and call a special telephone number only to have their hopes dashed by being told that there was no money. That is certainly not good health promotion. The approach was universally condemned. A cheer went up throughout New South Wales when this Government changed that approach. Let us do things properly and not raise people's hopes falsely. I repeat for the shadow minister for health: we have not abolished health promotion; we have upgraded it.
Mrs Skinner: I have met people who have been sacked from the unit!
Dr REFSHAUGE: What an unbelievable statement. The honourable member claims that people have been sacked from the unit, but it has been upgraded. [Time expired.]
Motion agreed to.
I find myself writing again in great frustration. It is 4.20 p.m. on a Friday afternoon and I have a patient, an insulin-requiring diabetic patient, in her early 60's, with several risk factors who has just had a presumptive diagnosis of a pulmonary embolus. I have rung Westmead Hospital to have her admitted but I'm told there are no beds for her. In fact they have closed 8 medical beds over the weekend as they apparently do every Friday.