Review of East Coast Health
Table of Contents
Summary and recommendations
Recommendations
2
2
Terms of reference, process for the review and questions to consider
Questions to consider
3
3
Strategic and demographic context
4
Present situation with medical and health services
5
Summary of events in the history of East Coast Health
8
Observations from the interviews
10
What goods and services should Local Government provide?
13
Potential sustainability of the East Coast Health Vision
14
Structural Options for East Coast Health
Comment on Structural Options
Comparison of Single Authority and Incorporated Association
16
17
18
Economic viability
18
Observations on questions from the terms of reference
21
Appendix 1: Summary of background documents and history
23
Appendix 2: The Medical Practice Management Agreement
31
Disclaimer
31
East Coast Health Review August 2013
2
Summary and recommendations
The intention of East Coast Health has been to secure medical services for the municipality. That objective
seems to have been achieved given the range and number of services that exist today.
The arguments and tensions around East Coast Health have been about money and emanate mainly from
Triabunna.
The current reality is as follows:
• There is a practice management agreement in place between Council and the Bicheno medical practice.
Council employs the staff at Bicheno.
• The doctors at Swansea manage their own practice and see no value in signing a practice agreement with
Council or an East Coast Health organisation.
• There is a practice management agreement in place between Council and Dr. Winston Johnsonʼs practice
in Triabunna.
• Doctor Naidoo operates an independent practice at Triabunna and does not want to enter into practice
management arrangements where Council has control. Doctor Naidoo employs his own staff.
• Both Triabunna medical practices operate out of the recently developed Triabunna Medical Centre, which
is owned and equipped by Council. Neither practice pays rent.
• Both Triabunna practices share Dr. Naidooʼs employees. Dr. Naidoo is paid 50% of his staff and
administration costs to enable this sharing arrangement. There is no contract between Dr.Naidoo and
Council formalising this arrangement and no formula to accommodate other health professionals operating
from the medical centre and sharing the staff. The sharing arrangement has problems and an
advertisement was placed to employ a receptionist for Dr. Johnson. Council and Dr. Naidoo are in dispute
over payments.
• A section (24) special committee of Council is in place with terms of reference it is unable to fully
implement.
• Council employs a Practice Manager on a part time basis (15 hours per week) at the Triabunna medical
centre. The original intention of this role was to provide practice management services to the East Coast
Health organisation. This has not eventuated.
It would take a lot of work to put an incorporated entity in place and it is not certain that the capacity to do so
exists in the community. Calculations indicate an incorporated entity, involving all doctors, would be
economically challenged without increasing the medical service charge and the percentage contribution of
patient income by doctors.
If an incorporated entity were formed it would only service one doctor in Triabunna (Dr. Naidoo). Other
practices have legally binding arrangements with Council or are happy managing their own practice.
Therefore it seems that the model for East Coast Health as a Council owned company or an incorporated
association is broken and cannot easily be put back together again under current circumstances.
Recommendations
There are five issues to address:
1. The staffing arrangements at Triabunna.
A staff-sharing contract needs to be agreed by the two doctors and Council. This must include a
formula to accommodate other health professionals practicing from the building. If the contract cannot
be agreed then Dr. Johnson will need to have his own staff and the sharing payments currently being
made to Dr. Naidoo cease. Alternatively the staff could become employees of Council with appropriate
transfers of entitlements and charging arrangements established.
2. Property leases between Council and doctors using Council owned properties to operate their
practices.
A lease needs to be developed with an appropriate rental and property use conditions. Council should
separately decide to remit the rent amount. This will make the rental contribution a community service
obligation of Council. As such it will be more transparent and the decision can take account of
conditions at the time.
East Coast Health Review August 2013
3
3. The future purpose of the East Coast Health Committee and the East Coast Health Practice
Manager position.
Given the current situation both appear to be redundant.
Council needs to formally decide the future of both the Committee and the Practice Manager position.
4. Councilʼs ongoing role as a medical practice administrator.
Council is contractually bound, at present, to Dr. Johnson and the Bicheno practice. When the
agreements expire Council should reexamine its role in this area.
Also consideration should be given to contracting with an appropriate organisation to assist with
accreditation services.
5. The formation of an East Coast Health incorporated entity.
This should not proceed until all medical practices agree and see benefit in its formation and the
sustainability factors in the community improve.
Terms of reference, process for the review and questions to
consider
Terms of reference
Review the vision for East Coast Health, associated governance models and sustainability.
Assess the current situation with the implementation of East Coast Health by clarifying the views of all parties
and considering background information.
Make recommendations for future direction.
Principles to guide the review
Respectfully listen to the views of those involved.
Be transparent and decensor the issues.
Be independent with no conflict of interest.
Process
Conduct interviews with members of the East Coast Health Committee and interested persons.
Review Council documentation on East Coast Health.
Undertake research on community based primary health organisations.
Questions to consider
1. Is the Council vision for managing health services in the municipality now possible?
2. Should Council be involved in providing support for medical and health services and to what extent?
3. If it is possible to establish a community-based entity to manage health services, what structural model is
appropriate?
4. Would a separate entity be sustainable and financially viable?
5. Is there sufficient capacity in the community to manage a separate entity?
6. What is the way forward?
th
The summary paper East Coast Health prepared by Jill Morgan on December 13 2011 also outlines legal
advice on issues that Council would need to consider when making a decision on a future structure.
They are:
• The benefits to Council of transferring assets relevant to East Coast Health in a separate legal entity.
• The benefits to Council of removing its current management and oversight responsibilities.
• Whether the operations of the facility are sufficiently complex and burdensome on Council to justify the
creation of a new body corporate.
• Whether the current committee or community members are going to want to take on the responsibility of
administering a body corporate.
• What level of autonomy does Council want East Coast Health to have over its operations?
• What are the significant benefits to be gained by Council that justify taking steps to create an independent
body, which must be administered according to legislation and rules?
East Coast Health Review August 2013
4
Strategic and demographic context
Strategic context to health services in the Glamorgan Spring Bay municipality
In the recently endorsed Glamorgan Spring Bay Community Strategic Plan there is a future direction called
“Foster Health and Wellbeing”. Within that direction is a strategic outcome that “communities have access to
local health and wellness services and facilities”. Council identified its role in the delivery of this outcome as
being a provider, facilitator and advocate.
There is also a future direction to “Age Well in Our Communities” and the strategic outcome that “Glamorgan
Spring Bay is an age friendly community where people want to live and this generates a range of employment
and training opportunities”. Council identified its role in the delivery of this outcome as a facilitator and
advocate.
The provision of medical services across the municipality will influence the achievement of these two future
directions and their associated strategic outcomes.
Demographics
Glamorgan Spring Bay has an area of 2,522 square kilometers and is 160 kilometers long from North to South.
Within the municipality are a number of towns that have traditionally looked to their own needs. There is not a
lot of evidence of collaboration between the settlements.
The municipality overall has 4,190 residents and a higher median age than Tasmania. It is a popular
retirement location and locally available medical services are important for retired people.
A generally accepted medical level of service is one fulltime equivalent doctor for 1,000 persons. A total
population of 4,190 suggests a need for four doctors.
Triabunna and Orford are very closely connected and a practice in this area would have access to 1,413
persons.
Coles Bay could access either Bicheno or Swansea for services. If the population of Coles Bay is equally
divided then a practice at Bicheno would have access to 1,005 persons and Swansea access to 924.
These figures do not include a distribution of the 20% of the population that live in other locations in the
Municipality, so there seems to be enough people to support four doctors.
The following table shows the main townships, population and median age. The data was sourced from the
2011 Census: population by place of usual residence. Unfortunately census data could not be separated for
Buckland and the other smaller communities.
Location
Number of
people
population
Male
%
Female
%
Median
Age
Bicheno
853
20.4
51.5
48.5
52
Coles Bay
Swansea
305
7.3
54.1
45.9
49
771
18.4
46.6
53.4
59
Triabunna
895
21.4
50.9
49.1
47
Orford
Other
locations
518
12.4
49.4
50.6
57
848
20.1
N/A
N/A
N/A
GSB Total
4190
100.0
50.6
49.4
53
% of total
East Coast Health Review August 2013
5
14"
12"
10"
8"
6"
4"
2"
0"
GSB %"
TAS %"
0 to 4"
5 to 9"
10 to 14"
15 to 19"
20 to 24"
25 to 29"
30 to 34"
35 to 39"
40 to 44"
45 to 49"
50 to 54"
55 to 59"
60 to 64"
65 to 69"
70 to 74"
75 to 79"
80 to 84"
85 +"
percentage"
Percentage of people by age group
Glamorgan Spring Bay and Tasmania"
Glamorgan Spring Bay is a popular holiday and tourism destination where people have holiday homes and
rental premises. This fact is reflected in the data on unoccupied dwellings at census time.
At the time of the 2011 census 55% of dwellings in the municipality were unoccupied. This percentage is
significantly higher than for Tasmania and Australia as a whole.
The unoccupied dwellings are predominantly holiday homes.
The following table shows the occupied and unoccupied dwellings in the townships. It can be reasonably
assumed that the occupancy of unoccupied dwellings would increase by three persons during holiday periods.
This means the population of Glamorgan Spring Bay doubles during these times. This has implications for the
provision of community infrastructure and health services.
Occupied
number
Occupied
%
Unoccupied
number
Unoccupied
%
Estimated
increase in
population
Bicheno
365
50.1
363
49.9
1089
Coles Bay
108
20.8
410
79.2
1230
Swansea
320
59.7
216
40.3
648
Triabunna
359
75.1
119
24.9
357
Orford
216
30.2
499
69.8
1497
Private
dwellings
Median weekly incomes for all categories are lower in Glamorgan Spring Bay than for Tasmania and Australia.
This reflects the high median age and number of retirees. It also means that people are less able to afford
medical fees or the cost of travel to access medical services.
Median weekly income
GSB
Tas
Aus.
Personal
422
499
577
Family
908
1203
1481
Household
753
948
1234
Present situation with medical and health services
There are four separate medical practices operating in the Glamorgan Spring Bay municipality.
Their locations are Triabunna, Bicheno and Swansea.
Triabunna
The Triabunna Medical Centre building and equipment is owned by the Glamorgan Spring Bay Council.
Two medical practices are located at the Triabunna Medical Centre.
Dr. Naidoo owns one and Dr. Johnson owns the other.
There is no lease in place between Council and the Practices.
East Coast Health Review August 2013
6
A Practice Manager is employed part time (15 hours per week) at the Centre. The Practice Manager is an
employee of Council, has no access to the Council medical account and is not involved with Bicheno. There is
a history of the Practice Manager regularly exceeding the budgeted hours of work without Council approval.
Attempts by Council to recover the over budget amounts from Dr. Naidooʼs practice has led to legal action.
Dr. Johnsonʼs practice has signed a medical practice agreement with Council. Council provides practice
support in return for a contribution of 25% of practice income.
Dr. Naidooʼs practice is privately managed and operates independently of Council.
Dr. Naidooʼs practice employs all staff at the Medical Centre with the exception of the Practice Manager.
Recently Dr. Naidoo reduced the opening hours of the medical centre without consultation with Council.
Council pays Dr. Naidooʼs practice 50% of the practice staff costs and administrative expenses.
This arrangement allows Dr. Johnson to receive staff and administration support from Dr. Naidooʼs practice.
Indications are that Dr. Johnson is not completely satisfied with arrangements and is seeking to employ his
own receptionist.
A physiotherapist has commenced operating from the Centre and has no relationship with Council.
Doctor Naidoo has billed Council for an increased percentage of staff and admin costs in return for the
Physiotherapist accessing help from his employees.
Bicheno
The Bicheno Practice is located at the Council owned Community Health and Resource Centre.
There is a Management Committee that cares for the centre. There is also the Bicheno Community Health
Group Inc. that raises funds for services like the community car.
The previous doctor (deceased) signed a medical practice agreement with Council and agreed to pay 25% of
practice income in return for staffing and administration services.
Council employs the practice staff.
May Shaw has assisted Council achieve accreditation for Bicheno.
Locums are currently running the practice but a permanent doctor from overseas is scheduled to commence
later in the year.
The overseas doctor will be a council employee for twelve months as part of the immigration arrangements.
The doctor will also require medical supervision for two years. After twelve months the doctor will cease being
an employee of Council and will sign up to the practice management agreement with Council.
Swansea
A husband and wife team shares the practice, which provides full time medical services from the May Shaw
Health Centre.
Space is rented from May Shaw. The practice operates independently of Council and provides a 24-hour
emergency service with two State funded sub acute beds.
The Swansea doctors see no advantage in signing the Council Practice Management Agreement.
Other organisations
The municipality is well serviced by a network of health organisations.
Location
Triabunna
Group or organisation
Comment
Medical Centre called East Coast
Health
•
•
Community Health Centre
•
•
•
•
•
•
•
•
•
•
Council owned and equipped building.
Houses two independent private medical practices for
doctors Johnson and Naidoo
The two doctors currently share staff.
Has space to provide additional allied health services.
Well equipped and modern.
Owned by State Government.
Houses community health nurses.
Conducts child health services.
Conducts state funded and HAAC health education
programs.
Conducts some outreach services.
Has rooms available for visiting allied health service
providers.
The Ambulance and Paramedic service is located in a new
extension to the building.
East Coast Health Review August 2013
Location
Group or organisation
Orford
Prosser House Day Care Centre
Swansea
May Shaw Health Centre
Bicheno to Buckland Healthy
Together
Community Health Centre
Bicheno
7
Bicheno Community Health and
Resource Centre
Comment
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
State Government and HAAC funded.
Offers group activities primarily for frail aged.
Provides day respite for carers.
There is Council involvement in coordination.
Is an incorporated association with a volunteer board.
Provides residential aged care and independent living units.
Has two sub-acute beds funded through State Government
for emergency services.
Provides respite and palliative care.
A dental service is located at the centre.
Houses a medical practice that is shared by two doctors.
Provides help at home programs.
Grant funded.
Rural Primary Health Program.
Managed through May Shaw for Council.
Has a board and executive officer.
State Government owned and managed.
Provides health and community services.
Accommodates community health nurses.
Council owned.
Has strong community fund raising support.
Has a management committee.
Houses a medical practice with one doctor.
Provides child health and development services.
Status of the Health Company vision
Council has not established a self-funding / self-supported Health Company wholly owned by Council. Instead
it has developed a Medical Practice Management Agreement, which establishes Glamorgan Spring Bay
Council as a practice administrator. This agreement has been signed by Dr. Johnsonʼs practice and will be
extended to Bicheno when the new doctor commences. The other two practices remain independently
managed. A summary of the agreement is contained in Appendix 2.
The East Coast Health Committee and Doctor Naidoo support a community-based model and are critical of
Councilʼs ability to manage medical practices. It is doubtful Dr. Naidoo will participate in any model where
Council has control.
Medical property charge
Council makes a separate medical service charge on properties to assist with the provision of medical
services across the municipality. The service charge funds incentive payments to all doctors in the municipality
to attract and retain their services.
The payments include:
• $11,000 per annum for rental assistance based on the doctor working 4 days per week
• $16,500 per annum for a motor vehicle subsidy (minimum 4 days per week work) or alternatively
Council will supply a fully maintained vehicle up to a capital value of $40,000
The service charge also helps meet the costs of locums, the depreciation of medical equipment and surgery
rental at Swansea.
The service charge does not fund costs associated with property ownership at Triabunna and Bicheno or
employee costs. It was intended for those costs to be recovered through the Practice Management
Agreement.
Council on behalf of the community is involved with a range of health and medical services.
Council Support
Triabunna Medical Centre
•
•
•
•
•
•
Comment
Owns and maintains the building.
Pays for utility costs.
Undertook fit out including provision of medical
equipment.
Meets cleaning costs.
Employs a part time Practice Manager.
Provides medical and financial IT support.
East Coast Health Review August 2013
Council Support
8
Comment
Pays 50% of Dr. Naidooʼs staff & administration
costs to provide services to Dr. Johnson.
• Pays rent for the doctors surgery.
• Owns building and practice equipment.
• Pays for utilities.
• Employs staff.
• Provides medical and financial IT support.
All full time doctors receive payments for housing and
vehicle support
Obtains rural health grant funding for the “Bicheno to
Buckland Healthy Together” program which is
delivered through May Shaw Health Centre.
Owns and maintains eldercare units
Provides insurance cover for volunteers.
•
Swansea medical practice
Bicheno Health and Resource centre
Recruitment and retention of doctors
Rural Health
Aged care
Insurance
Summary of events in the history of East Coast Health
Appendix (1) provides a chronological listing of documents together with anecdotal information, derived from
interviews, that provides background to the East Coast Health issue. The lengthy list can be summarised as
follows:
In the 1990ʼs Doctor Naidoo purchased a medical practice located at what is now the Community Health
Centre. Under State Government arrangements at that time the practice received rent-free premises, the use
of community nurses for practice purposes and materials at no cost. There was no documentation detailing
these arrangements.
The practice prospered but was unable to meet full community demand for medical services. People who
could not access Dr. Naidooʼs practice travelled to Sorell, Richmond and Swansea. Elderly community
members found this difficult and demand for an additional doctor grew.
Discussions between Council and Dr. Naidoo about the future provision of services began around 2005.
Council provided financial assistance to Dr. Naidoo to help meet the costs of locums needed when he took
leave. Payments amounting to $19,000 were made between 2008 and 2010.
Around 2008 Council started discussions with the State Government about extending the Community Health
Centre building to accommodate additional doctors. Issues around property ownership complicated
negotiations. Council owned the land on which the State owned building was located. In the end Council
transferred title to the land to the government. The building was eventually extended to accommodate an
ambulance and para medic service.
During this period the government, facing budgetary pressures, began reviewing assistance provided to
private medical practices at Community Health Centres. This created tension with Dr. Naidooʼs practice and
resulted in the community health nurses not providing practice-nursing assistance. The practice accessed
federal funding to assist with the employment of practice nursing staff. Dr. Naidoo was stressed by the
uncertainty caused from changing government arrangements. He convened a small group of his patients to
start exploring a community directed health management model.
Through 2009/10 community dissatisfaction with the availability of medical services continued and a public
meeting was called. This resulted in the State Health Minister forming a community based health consultative
committee. This functioned for a while but lack of government commitment caused it to lapse.
The northern end of the municipality was also having difficulty attracting doctors. A professional practice
management company River Medical from West Australia was retained to provide doctors and practice
management. This later became Gemini and then IPN. Council levied a medical service charge on properties
in the northern end of the municipality, to provide a package of incentives to the doctors in Bicheno and
Swansea. The State Government also contributed funding.
East Coast Health Review August 2013
9
Dr. Naidoo objected to this on equity grounds and in July 2010 the incentive package was extended to all
doctors in the municipality. It included vehicle and housing support. Extending the medical service charge to all
properties across the municipality funded this arrangement.
In 2010 Council issued a paper outlining a vision for a self-funding and self-supported Health Company for
Glamorgan Spring Bay wholly owned by Council. The company would provide practice management support
and employees to all medical practices in the municipality and would help facilitate resource sharing,
arrangement of locums and sharing of after hours work.
In 2010 Council recruited Dr. Winston Johnson to work in Triabunna. He was given the doctorʼs incentive
package and an allowance to be paid whilst he developed his practice to the level he had achieved on the
West Coast of Tasmania. Council also agreed to provide practice administration services to Dr. Johnson for a
fee equivalent to 25% of patient income. Dr. Naidoo was concerned about the conditions provided to Dr.
Johnson.
Council entered into an interim arrangement with Dr. Naidoo to share his practice staff and administration with
Dr. Johnson. Council paid 50% of costs for Dr. Naidooʼs staff, administration and medical supplies.
It was Councilʼs expectation that Dr. Naidoo would enter into the same practice management arrangements as
Dr. Johnson so that the vision for a self-supporting health company could be realised. Discussions
commenced about transferring Dr. Naidooʼs employees to Council.
Temporary arrangements were made with the State Government to house Dr. Johnsonʼs practice at the
Community Health Centre alongside Dr. Naidooʼs practice. Conditions were crowded and not ideal.
Relationships with the community nurses were strained. Council committed resources to redevelop and equip
the “Old Forestry Building” as a Medical Centre.
After Dr. Johnsonʼs commencement Council decided to form a special committee of Council to get involved in
realising the East Coast Health Vision. An advertisement seeking applications from interested community
members was placed in the Mercury newspaper. After about six months the East Coast Municipal Health
Committee was formed. In June 2011 the Committee developed terms of reference. The terms of reference
were wide ranging and included an objective to form a Medical Centre Model as well as a range of operational
tasks to work on with Council management.
In June 2012 the professional practice management company IPN ceased providing services to Bicheno and
Swansea.
Councilʼs lawyers drafted a Medical Practice Management Agreement, which was given to the East Coast
Health Committee to consider. The Agreement set out responsibilities for the practice manager (Council) and
doctor involved. East Coast Health Committee minutes indicate that the contract was reviewed by the doctors
on the committee and was accepted.
Work started on the forestry building in early 2012 and the committee began to consider issues associated
with forming a community based independent entity to achieve the vision outlined by Council. They canvassed
support from the Swansea and Bicheno doctors. Swansea doctors saw no value in changing their existing
arrangements. Bicheno eventually agreed to participate.
A Practice Manager was employed by the East Coast Health Committee to provide assistance moving to the
new premises. It was planned extend the Practice Manager role to the Bicheno practice. Council employed the
Practice Manager on a part time basis. The hours of work in the contract were 15 hours per week to work at
Triabunna. If the role extended to Bicheno the hours would increase to 22.5 pw.
Dr. Naidooʼs practice and Dr. Johnsonʼs practice moved into the new Medical Centre in August 2012
The Bicheno practice signed the Medical Practice Agreement and Council employed the practice staff.
Dr. Johnson also signed the Medical Practice Agreement.
Dr. Naidoo did not sign the Practice Agreement and Council extended the arrangement to provide Dr. Naidoo
with 50% of his staff, administration and medical costs.
The failure by Dr. Naidoo to sign the Medical Practice Agreement after moving into the new centre was a
disappointment for Council. Doctor Naidoo wanted to sign an agreement with a community-based
organisation. Council and Dr. Naidoo fell into dispute and Council decided to enter into mediation.
East Coast Health Review August 2013
10
Dr. Naidoo did not support the mediation process and it did not go ahead.
The failure by Council to establish a community based entity to provide practice management services caused
tension between the East Coast Health Committee, Dr. Naidoo and Council.
Dr Naidoo wanted a community based entity and did not want to pay Council for practice administration.
Over the past 12 months, relationships between Council management, the East Coast Health Committee and
Dr. Naidoo became strained.
Arguments started over doctorʼs bank accounts, councilʼs financial management and the housing of patient
records on Councilʼs server.
The contracted working hours of the Practice Manager were regularly exceeded without reference to Council.
The view developed that he was directly working for Dr. Naidoo not Council.
There were problems with Bicheno doctors correctly using the IT System.
The Triabunna Medical Practice hours were reduced by Dr. Naidoo without reference to Council.
An advertisement was placed for a receptionist for Dr. Johnson because it was felt the sharing arrangements
were not working.
Nursing and reception staff at the Triabunna Medical Centre continued to be employed by Dr. Naidoo.
A physiotherapist commenced working from the Triabunna Medical Centre and this sparked an argument with
Dr. Naidoo about the percentage to be used when reimbursing staff and administration costs. A disagreement
over invoices between the Council and Dr. Naidoo resulted in Dr. Naidoo referring the matter to his solicitors.
That legal situation is continuing.
Around the community rumours began that Council was trying to remove Dr. Naidoo. Also Councilʼs ability to
manage a medical practice was questioned. Trust and respect in the relationship between Council
management and Dr. Naidoo eroded. This frustration has extended to the East Coast Health Committee.
The East Coast Health Committee and Council decided to undertake an independent review to find a way
forward and groupwork pty ltd was asked to assist. Dr. Naidoo questioned the independence of groupwork pty
ltd and chose not to participate in the review.
Observations from the interviews
28 people were interviewed either face to face or over the phone. Some people were invited to participate
whilst others called and requested an opportunity to put their view. Their details are set out in the table below.
Doctor Naidoo was asked on three occasions to participate in the review but he chose not to do so.
Date
Name
Position and involvement
4/7/2013
David Metcalf
4/7/2013
4/7/2013
5/7/2013
5/7/2013
26/7/2013
Jenny Woods
Craig Johnston
Jill Morgan
Dr. G Davidson
Beth Wyllie
26/7/2013
26/7/2013
26/7/2013
26/7/2013
Neil Edwards
Jean Weeding
Shirley Castles
Dr. W. Johnson
26/7/2013
1/8/2013
1/8/2013
Sue Khan
Lyn Taylor
Dana Douglas
1/8/2013
2/8/2013
Julie Orr
Eileen Bailey
5/8/2013
Sandra (Harry)
Higgs
Chris Haigh
Claudia Walker
General Manager of Glamorgan Spring Bay Council and member of the East Coast
Health Committee (ECHC)
Glamorgan Spring Bay Councillor and member of the ECHC
Glamorgan Spring Bay Councillor and member of the ECHC
Chair of the ECHC
Medical practitioner and member of the ECHC
Works for Dr. Naidoo and was involved in the early work setting up the ECHC and
designing the model
East Coast businessman and community member of the ECHC
Community member, member of Rotary and past employee of Dr. Naidoo
Community member, works in aged care at Orford and a past employee of Dr. Naidoo
Medical practitioner at Triabunna and has signed an agreement to contract Council as
practice manager.
Manager of the Community Health Centre at Triabunna
Community Health Nurse and community member of the ECHC
Involved with the Rural Primary Health Service, Bicheno to Buckland Healthy Together.
Community member of the ECHC
Manager of May Shaw Health Centre Inc. based in Swansea
Community member who was involved on the original committee to explore East Coast
Health (by phone)
Practice Nurse at the medical centre in Triabunna. An employee of Dr. Naidoo (by
phone)
Receptionist at the medical centre at Triabunna. An employee of Dr. Naidoo
Receptionist at the medical centre at Triabunna. An employee of Dr. Naidoo
8/8/2013
8/8/2013
East Coast Health Review August 2013
Date
Name
Position and involvement
8/8/2013
8/8/2013
8/8/2013
8/8/2013
8/8/2013
9/8/2013
9/8/2013
13/8/2013
16/8/2013
Melissa Cruse
Helen Burnell
Philip Pyke
Ian Montgomery
Peter Hill
Phil Edmondson
Susan Powell
Dr A Grove
Denise Parr
Receptionist at the medical centre at Triabunna. An employee of Dr. Naidoo
Practice Nurse at the medical centre in Triabunna. An employee of Dr. Naidoo
Practice Manager for East Coast Health, a part time employee of Council
Pharmacist based in Triabunna
Community member with a long involvement in local health management issues
CEO Medicare Local Tasmania
Director Population Health Programs Medicare Local Tasmania
Medical practitioner at Swansea
Employee of Dr. Naidoo (by phone)
11
Each person interviewed was asked four open questions:
• What are your thoughts on the East Coast Health Vision and model?
• What obstacles are stopping it going ahead?
• What should be done to move the vision forward?
• Do you have any other comments to make?
Observations from the discussions
The observations show a spectrum of views from positive to quite negative.
Most people thought that East Coast Health was a good idea but there was evidence of misinformation and
rumours. Not everyone had a clear understanding of how the East Coast Health model would work. The
interviews provided an opportunity to discuss facts and address misunderstandings.
There were no clear views about a way forward or apparent knowledge of the steps needed to form any
community-based structure.
On the one hand Council support in a future structure was seen as needed. On the other hand Council was
criticised for providing practice management services.
Thoughts on the East Coast Health Vision and Model
• East Coast Health is a good idea and could work. It is a vision for the future, which is getting distracted by
present day issues.
• The model would provide a bigger core that could attract GPʼs, provide relief and flexibility and potentially
attract Registrars.
• The model can work but will need the cooperation of all doctors.
• Dr. Naidoo initiated a model based on community ownership.
• Could have some advantages but needs more definition.
• East Coast Health has the potential to bring all parts of the municipality together in a community-controlled
organisation governed by a steering committee and an ethics board.
• Could save money by having a common practice manager across the three towns using common
software. However I need to be satisfied that the practice manager was competent and stable from an
employment aspect
• The initial vision was to have a network of health providers on the East Coast working in coordination,
providing locum assistance sharing responsibilities like after hourʼs emergency services. Council was to
provide premises and admin support like payroll, IT and accounts payable and receivable. The doctors
would provide a % of their income to pay Council for the services.
• Dr. Naidoo had a vision to train registrars in rural health.
• Would be good to get assistance with accreditation through East Coast Health.
Obstacles stopping it going ahead
• Donʼt want to participate in something and have it fall over
• Dr. Naidoo is prepared to work with a community-controlled organisation but does not want to hand control
to Council.
• Everyone is concentrating on Pranesh not East Coast Health.
• Council changed the rules.
• Council moved from a draft contract to reality without consultation.
• The Council arrangement is not transparent.
• You donʼt need East Coast Health to arrange after hours or locum assistance. This can be done directly
through cooperative relationships between doctors
• Dr. Naidoo moved into the new building without signing the management contract and things have gone
badly ever since.
East Coast Health Review August 2013
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
12
There is tension between the two doctors (Naidoo & Johnson) about staffing.
Dr. Naidoo wonʼt sign up to anything that has David Metcalf in control of the practice management
company.
Dr. Naidoo does not want to donate his practice to Council.
The Swansea doctors donʼt want to join the East Coast Health model.
The management contract was not signed because the company had not been formed. Dr. Naidoo wonʼt
sign if David Metcalf is in control of the company. He wants a community-based model.
Bicheno needs to settle down after the death of their doctor.
Dr. Naidoo wants a model to hand his practice to. He does not want to lose control to Council and put his
life into the Council mire.
Need a board of management separate from Council. Practice management is not a core function of
Council.
Dr. Naidoo employs all the staff at the Triabunna Medical Centre. Dr. Johnson has no say with the staff
and feels administration is not working. He wants his own staff.
Dr. Johnson has a separate practice but Dr. Naidoo treats him as though he is part of Dr. Naidooʼs
practice.
Decisions around East Coast Health have not been transparent.
There is a legal issue between the Bicheno and Triabunna practices concerning the sharing of software
and patient records. This could affect accreditation.
There are confused legal relationships for the Triabunna staff between the two doctors.
East Coast Health is Dr. Naidooʼs practice.
Dr Naidoo is over-using the practice manager and this is costing Council. Dr. Naidoo feels it is own
practice and Dr. Johnson should be working for him.
The model proposed by Dr. Naidoo was unique and Councillors back off when it is mentioned. They donʼt
know enough and do not want to move out of their comfort zone.
Dr. Naidoo is an idealist who wants the community to manage East Coast Health. Practically speaking
there is not the will or the capacity in the community to take on the task of managing a community owned
East Coast Health organisation.
There are two models: community based and Council operated. Council is treating East Coast Health as a
business enterprise.
The crux of the matter is that Dr. Naidoo still thinks the practice is his. He bought it when he arrived.
There is a clash of wills between Dr. Naidoo and David Metcalf, which is a shame because they are both
good people.
The honesty between Dr. Naidoo and Council has been lost. Lawyers are now involved.
Dr Naidoo is a good doctor but can be idealistic and hard to work with.
David will not let go of the chequebook. The Practice Manager cannot buy a band-aid.
What should be done to move the vision forward?
• Start afresh and disband the committee. The current committee is too personally immersed in the issue.
• Remove Dr. Naidoo from future arrangements.
• Need some boundaries to stop people doing what they want.
• Need to move on and ignore Dr. Naidoo.
• Disband the committee.
• The issues of East Coast Health and the practice support are separate things and have been confused.
• Simplest thing is for a separate structure.
• Not sure that the model would be self-sustaining but the levy could be a mechanism for balancing the
books.
• Community needs to know what is going on.
• Community needs to be empowered to manage its own health.
• Any future structure needs an Ethics Board, which is a mechanism for transparency.
• Dr. Naidooʼs practice could operate on its own which it is doing now.
• Need to put the matter to rest and find out exactly what Dr. Naidoo wants.
Other comments
• Dr. Naidoo is a good doctor and has community support.
• David Metcalf has performed well as General Manager of Council. He gets things done.
• David Metcalf is a man of many talents but should not be a medical practice manager.
• David has done a lot to advance health on the East Coast.
• There is an underlying motive to get rid of Dr. Naidoo.
• No point demonising Dr. Naidoo.
East Coast Health Review August 2013
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
13
There is a lot of community concern about losing Dr. Naidoo.
There were similar difficulties with Dr. Naidoo when the Department of Health and Human Services started
reviewing arrangements at Community Health Centres.
There is concern about the independence of the review.
The review needs to be independent, transparent and not a witch-hunt.
There are concerns about the efficiency of Council processes.
Practice management is complex and regulated. Maintaining accreditation is important. Not sure this is a
role for Council.
Advertisement for Dr. Johnsonʼs receptionist was divisive.
The advertisement for Dr. Johnsonʼs receptionist was not helpful.
It would not be sensible to have two sets of staff in the one building.
Medical records are held on Councilʼs computer system. Who has access? Is this a risk to confidentiality?
It is not right for patient files to be held electronically by Council.
There are issues with the IT system and the ability of the phone system to queue patients.
Different software is being used. Bicheno and Triabunna (Medical Director), Swansea (Medtech). Both
packages have problems. The best software seems to be Best Practice. Implementation of Best Practice
across the three areas sounds attractive but would not want changeover to fail.
The Bicheno doctor incorrectly used the IT system.
There are billing issues at Bicheno.
Dr. Naidoo should not be forced to hand over 100% of his income and rely on Council to get 75% back.
Decisions about East Coast Health have not been transparent. The community needs to know what is
going on.
There has been a lack of community information.
The new medical centre is a great place to work and is well equipped.
The new medical centre could be a great community resource attracting allied health practitioners.
Dr. Naidooʼs employees were given forms to transfer employment to Council but the process did not go
ahead.
The recent change in the medical centres opening hours was done to help Dr. Naidoo with wages. Staff
agreed to the change and were not forced to reduce hours.
The ideal population to be serviced by a GP is 1,000. Numbers like 1,600 indicate under doctoring. The
average in Tasmania is around 1,200 persons per full time GP. What constitutes a full time equivalent for
a GP needs definition.
Not sure 25% of doctors earnings is a sufficient contribution.
25% of earnings for practice management services is a bargain.
Practices in the City pay around 40%.
Medical practices get federal government support through Medicare for practice improvement programs.
This involves subsidies for after hourʼs care and hiring practice nurses. There are also specific programs
and health initiatives from time to time.
The situation at Triabunna needs to be resolved. Tasmania is a small place and problem areas are known
and avoided.
Doctors avoid working in areas where the community is divisive.
What goods and services should Local Government provide?
There is no standard answer to this question but the following concepts may assist in making a judgment:
•
Market failure; the inability of the private sector to provide a good or service for reasons like lack of
capital or profitability. This can change as conditions alter. In the early days of settlement there were
no private garbage contractors so Local Government took on the role for reasons of public health.
Today there is a competitive market in the waste disposal business so Councils can contract the
operations to the private sector.
•
Public goods; these could be described as the core business of Local Government. Councils provide
public goods to the whole community. There are no restrictions on their use and everyone has equal
access to them. They are usually funded from rates and grants. Examples include good town
planning, recreation in a public park, access through footpaths and a local road.
East Coast Health Review August 2013
14
•
Merit or expected goods, which exist when there is a degree of market failure. The private sector does
not find them profitable to provide but the community believes Councils should provide access to them
on equity grounds. They are funded through a mix of rates, grants and user charges. An example is a
council provided swimming pool that has entry charges and operational subsidies. There is no
obligation for Councils to get involved in the provision of merit goods. The decision to do so is political.
•
Private or commercial goods where there is no market failure. They are funded by price and people
choose if they want to pay for them or not. Generally Councils do not get involved in the provision of
private goods. However if they do the profits should be sufficient to meet capital and labour
requirements without subsidy. Off street car parking in cities could be an example.
The following table summarises this framework:
Activity type
Core
Expected
Economic classification
Public goods
Merit goods
Basis for pricing
Taxation
User pays and subsidies
Commercial
Private goods
Competitive commerciality
Revenue types
Rates & Government Grants
Rates, Government Grants and
Charges
Prices & sales
Where do medical practices sit in this framework?
Generally people do not have unrestricted access to private medical practices so they are not public goods.
They could be viewed as business undertakings, which would make them private goods.
However governments at all levels provide financial assistance to medical practices for services such as: after
hours care, practice nursing and health initiatives. In rural and remote areas it can be difficult to attract and
retain medical professionals, which could be described as market failure. This has been the case on
Tasmaniaʼs East Coast. Also medical practices are funded through a mix of charges and government grants
which makes them merit or expected goods.
Around Australia particularly in rural and remote areas it is not unusual for Local Government to be involved in
the provision of medical services. The extent of involvement is a product of local needs and expectations. The
decision to be involved is political, guided by a sense of equity. Changing circumstances can alter the level of
involvement.
Community expectations caused Glamorgan Spring Bay Council to assist with the provision of medical
services by providing infrastructure and incentives to doctors.
Providing practice management support through East Coast Health is an extension of this approach and a
response to perceived market failure. However the long-term sustainability of this decision needs to be
considered.
Potential sustainability of the East Coast Health Vision
Sustainability is broadly defined as the ability to independently continue operation over time, economically and
with good governance support and relationships.
A discussion paper prepared by John Humphryes (Monash University School of Rural Health Bendigo) &
John Wakerman (Centre for Remote Health: A joint centre of Flinders University and Charles Darwin
University, Alice Springs) called “Primary health care in rural and remote Australia: achieving equity of access
and outcomes through national reform” was referenced.
The paper discussed issues associated with rural and remote health service delivery and made observations
about a recommended model.
The table below used this work to summarise a range of elements that can build or work against sustainability.
Reviewing the factors is useful when considering the current sustainability of East Coast Health.
East Coast Health Review August 2013
Element
Givens
Policy framework
Government
Relationships
Community
Readiness
Governance,
Management and
Leadership
Funding
Linkages
Infrastructure
Workforce
15
Builds Sustainability
Works against Sustainability
Sufficient population to support the range of services required
If taking a regional approach the full range of needs should be taken into consideration,
including health, aged care, community services.
•
There is no ʻone size fits allʼ and each community needs to plot its own journey
• Multiple models can co-exist within a region
•
Common vision that guides investment,
•
No vision, strategies or evaluation
capacity building and service
framework
development.
•
Ad-hoc grants
•
A strategic plan with a monitoring and
•
Being a pilot program
evaluation framework
•
Trusting and collaborative relationships
•
Distrust
•
Cooperative approaches
•
Turf wars, silos and demarcation.
Planned interdependent relationships that:
•
Dependent relationships where decision•
Build community ownership and trust
making is not inclusive
•
Use of local knowledge
•
Differing expectations
•
Understand needs
•
Tensions and conflicts.
•
Facilitate acceptance of change
•
Distrusting relationships
•
Ensure services are responsive
•
Shared leadership
•
Lack of capacity in core leadership skills
– governance, strategic planning,
•
Champions
management, change and
•
Governing committees / community boards
communications
•
Localised management
•
Unspecified boundaries
•
Accredited management
•
Conflicts of interest
•
Protocols in practice management
•
Poor management
•
Lack of protocols and procedures
•
Funded to succeed
•
Funded to fail
•
Secure funding sources
•
With other organisations
•
Insufficient linkages
•
Effective and productive working
•
Tensions between organisations
relationships
•
Lack of support
•
Accommodation for visiting health
•
Ad-hoc
professionals
•
Replicate existing facilities
•
Making best use of existing physical
•
Lack of protocols around processes and
infrastructure
systems
•
Telehealth and telemedicine
•
Differing IT systems
•
IT systems
•
Poor transport options
•
Viable transport options
•
Sound recruitment, selection and retention •
Poor living facilities and services e.g.
processes
housing, other employment, childcare,
education and therefore inability to
•
Teamwork and role delineation
attract professional workers
•
Staff authority
•
Lack of meaning in the work undertaken
•
Mentoring and career pathways
•
Lack of dignity – not being valued
•
Professional development
•
Lack of community in the workplace
•
•
A qualitative assessment of the present situation with East Coast Health against the sustainability factors is
put forward below in the next table. It suggests more work is needed to build sufficient community capacity to
achieve a sustainable environment for the East Coast Health vision.
Element
Givens
Policy
Government relationships
Community engagement
Governance management
& leadership
Low
2
3
4
High
Comment
Population is sufficient.
Different models exist already.
Vision is not shared.
There is no strategic plan or measurement
framework.
State and Local Government do not seem to
be working together on East Coast Health.
There are differing views and mixed levels of
understanding about East Coast Health. The
whole system does not appear engaged.
Local Government has shown some
leadership. A special committee exists but
there is tension and roles are not clear.
East Coast Health Review August 2013
Element
Low
16
2
3
4
High
Funding
Comment
A separate charge for medical services is in
place. There is the potential for a revenue
stream from doctors. Government grants are
accessed.
There are a number of organisations but little
evidence of a coordinated approach.
Infrastructure at Triabunna and Swansea is
well developed. IT systems are in place.
The workforce seems competent but there are
a variety of employment arrangements.
Professional development is not coordinated.
Linkages
Infrastructure
Workforce
Structural Options for East Coast Health
Initially the General Managerʼs vision for East Coast Health was a self-funding / self supported health
company in the Glamorgan Spring Bay municipality wholly owned by Council.
The formation of the company has not happened. Instead Council has contracted with Dr Winston and the
Bicheno practice to provide practice administration services, which broadly include accounting, the
arrangement of locums and accreditation.
The East Coast Health Committee is in place with a wide term of reference. Within the term of reference are a
number of operational tasks to be performed by the Committee in conjunction with Council officers. To
adequately complete the tasks the Committee needs operational resources and a close working relationship
with Council. The tasks also take the role of the East Coast Health Committee beyond that of advice and
advocacy. They appear to be describing the work of the board of a practice management company. A section
24 committee, without resources or delegated authority, is not the vehicle to do this work.
The East Coast Health Committee and Dr. Naidooʼs practice are advocating a community based incorporated
association that is associated in some way with Council. Presumably this entity would provide practice
management services in addition to coordinating, facilitating and advocating for health services.
Councilʼs ability to be involved in any corporate entity is governed by the Local Government Act (LGA).
The relevant sections are set out in the following table and indicate the options available.
Section of LGA
Section 20
Functions and
powers of a
Council
Section 21
Enterprise powers
Power
To provide for the health safety and
welfare of the community.
•
To represent and promote the interests of
the community.
•
To provide for the peace order and good
government of the municipal area.
•
In performing its functions a council is to
consult, involve and be accountable to the
community.
•
A council may do anything necessary or
convenient to perform its functions within
or outside its municipal area.
•
A council may transfer assets liabilities
and employees to a single authority.
•
Council may deal with property and sue or
be sued in its corporate name.
Enables Council to:
•
Form a corporation, trust, partnership or
other body.
•
Acquire and dispose of shares,
debentures or other securities of a
corporation.
•
Become a member of a company limited
by guarantee.
•
Acquire or dispose of units in a trust.
•
Acquire or dispose of an interest in a
•
Requirements & Comments
Council has the power to become involved in
the provision and management of medical
services.
•
•
•
A motion by Council to exercise enterprise
powers must be accompanied by a
statement of objectives of the exercise of
the power.
Ministerial approval is required if
exercising enterprise powers involves an
expenditure of $250,000 or 5% of general
rate revenue whichever is the greater.
The Minister may require Council to invite
submissions from the public or conduct an
East Coast Health Review August 2013
Section of LGA
•
•
Power
partnership or other body.
Enter into arrangements with any person
engaged in a business conducted to
directly or indirectly benefit the
community.
Undertake a project not authorised by the
LGA for the purpose of raising revenue.
Section 29
Controlling
Authorities
Council can establish a controlling authority to:
•
Carry out any scheme, work or
undertaking on behalf of Council.
•
Manage or administer any property or
facilities on behalf of Council.
•
Provide facilities or services on behalf of
Council.
•
Carry out any other functions on behalf of
Council.
Section 30
Single Authority
A single authority is a body corporate with
perpetual succession and a common seal.
A single authority may be established to:
•
Carry out any scheme work or undertaking
•
Provide facilities or services
•
Perform any function or exercise any
power of a Council under the LGA or any
other Act
17
Requirements & Comments
elector poll, consider submissions or the
poll results and provide any information
the Minister requires.
Council can determine:
•
Membership
•
Term of office and remuneration of
members
•
Proceedings, powers and rules
Council may by resolution remove a member
from the authority.
Council can abolish the authority.
Liabilities incurred by the authority can be
enforced against the authority or Council.
A controlling authority is not a body corporate.
Council is the corporate entity.
To establish a single authority Council must:
•
Give notice to the community through a
newspaper advertisement and a notice
displayed conspicuously at the Council
office.
The notice must set out:
•
Authority purpose
•
Membership of the authority
•
How the rules can be obtained
•
How submissions relating to the authority
can be lodged
•
Dates for submissions
The rules can be approved after:
•
Submissions have been considered and
amendments made.
•
A legal practitioner has certified the rules
as lawful.
After the rules have been approved a notice
must be placed in the Gazette to establish the
Authority.
The Authority must provide quarterly reports
and an annual report to Council.
The authority must also notify Council of any
adverse developments that could affect
financial viability or operational ability.
Council can wind up an Authority by absolute
majority vote or by the Minister following an
enquiry.
The rules may provide for a board of
management and a CEO
Comment on Structural Options
•
Council could exercise its enterprise powers to become involved in a community based incorporated
association subject to the financial limits that require Ministerial approval.
•
A Controlling Authority could be established given Councilʼs ownership of the properties in which the
Triabunna and Bicheno medical practices are located. However the practice management role could be
beyond the scope of a controlling authority. Also the control that Council would exercise may make this
option unacceptable to the East Coast Health Committee and Dr. Naidoo. A controlling authority is not a
corporate entity in its own right so it is probably not an option.
•
A Single Authority is a corporate entity and can be set up to operate as an accountable, organisation
separate from Council with a board, chief executive and employees. It has to operate within its rules and
regularly report on performance but is expected to operate in an independent and commercial way. Setting
East Coast Health Review August 2013
18
up a Single Authority does require a number of prescribed steps that take time and consideration. There is
a possibility that the community overall could object to the formation of the Authority. However if the
implementation process went smoothly a Single Authority would be an option that provides independent
management and Council involvement. It would take a committed and detailed effort to establish and
maintain.
•
A Community Incorporated Association.
The community could organise to form an incorporated association with or without Council as a member.
The not for profit association would need to have management contracts with member medical practices
to ensure cash flow. It would also need to provide its own accounting arrangements and IT system. Lease
arrangements with Council as the property owner would need to be negotiated. Council could continue to
administer the incentive payments to doctors outside of the associationʼs activities or transfer the funds to
it. There would need to be community capacity, collaboration and the willingness to take risk for this to
succeed
Comparison of Single Authority and Incorporated Association
Single Authority
Incorporated Association
Community
Council elected by the community
Council determines purpose and rules
Community
Members drawn from the community.
Members determine objectives and purpose. The
Tasmanian Model Rules can be used.
Associations Incorporations Act 1964 applies.
Formed according to provisions of Local
Government Act
Council appoints Board and determines term of
office
•
Council Representative
•
Medical Representative
•
3 Community representatives (skills based)
Board appoints office bearers
•
Chair
•
Deputy Chair
Board employs Manager.
Practice staff are employed by the single authority
and responsible to the Manager
Authority reports quarterly to Council
An annual report provided to Council at an AGM
Members appoint Office Bearers. Thereafter office
bearers elected at AGM.
President
2 Vice presidents
Treasurer
Public officer / secretary
Office Bearers can form an executive committee
Office Bearers employ Manager.
Practice Staff are employed by the Association
and responsible to the Manager.
Office bearers can determine accounting and
reporting requirements.
Annual return lodged with Office of Consumer
Affairs and Fair Trading.
Economic viability
An operating statement, which could apply to either an incorporated association or a single authority, has been
developed.
Both alternatives enable an independent, self-managing, entity providing practice management services.
For the purposes of this exercise the entity is called the Practice Management Company (PMC)
The operating statement for the PMC is built on the following assumptions
• The PMC will have a paid board of five members. The work requirements of the PMC are beyond the
scope of a voluntary board. The board when appointed should include a Council representative, a medical
representative and three skills based appointments from the community. The original Council company
vision proposed a board of 12, which is unwieldy for a commercial operation.
• Broader community engagement can be achieved through an advisory committee which includes other
health organisations and interested community members. It could meet with the board twice yearly to give
community feedback.
• There are four independent practices included in the model, two at Triabunna, one at Bicheno and one at
Swansea. Clearly practice agreement would be needed for the model to become a reality
• Surgery hours are 9 am to 6 pm with an hour closed for lunch. That is 8 hours per day, 5 days pw.
East Coast Health Review August 2013
•
•
•
•
•
•
•
•
•
•
19
Doctors and staff work 250 days (excludes weekends and 11 public holidays). It is assumed a locum will
cover annual leave so revenue continues to be generated.
Doctors see 31 patients a day and bulk bill. This is a conservative position. The figure produced by this
calculation has been increased by 25% to recognise that not all patients are bulk billed.
Doctors contribute 25% of their income to the practice management company for administration, staffing
and accreditation services
The Practice Manager is a general management role with a focus on accreditation at each practice.
Staffing at Triabunna would be shared between two practices and include:
o 2 FTE equivalents for reception and admin
o 1 FTE equivalent practice nurse
Staffing at both Bicheno and Swansea would include:
o 1 FTE equivalent for reception
o 1 FTE equivalent practice Nurse
The wage rates for staff have been loaded by 25% to cover on-costs.
No provision has been made for locum costs. It is assumed the doctors would roster leave periods
No income from Allied Health Service providers has been included
5,271 properties pay the $40 health charge levied by Council
The PMC has an estimated operating loss of around $270,000.
There is little opportunity to reduce expenses, as the practices are geographically separate. If it was possible
to combine the practices at one location there could be potential staff savings.
Increasing the doctorʼs contribution to 35% and the medical service charge to $60 would reduce the deficit to
around $10,000. This could be further lowered by Allied Health Provider contributions.
However it will be a challenge for the PMC model to be economically viable based on the proposed 25%
contribution by doctors and the current medical service charge.
East Coast Health Review August 2013
Income
20
Amount
p.a.
Notes
Medical Charge
$200,000
Council Rate charge $40 per property
Doctors contribution
$350,000
25% income
Practice incentive payments
$120,000
For nurses at four practices
Other grant payments
$100,000
Not specified
Total income
$770,000
Expenses
Board costs
Chairman
$25,000
Board fees
Four directors
$48,000
Board fees $12,000 per director
Advisory Committee costs
$2,000
2 meetings per year
Meeting and travel costs
$7,000
Catering, Secretarial, Mileage
Sub total Board costs
$82,000
Employee costs
Practice Manager wages plus on costs
$100,000
Manager of four practices Exec Officer
Administrative wages plus on costs
$200,000
4 practices 1 receptionist each
Nursing wages plus on costs
$278,438
3 practices 3 nurses. Triabunna shares
Superannuation
$43,500
Workers compensation
$5,000
Uniforms
$1,000
Training & development
$4,000
Sub total employee costs
$1,000 per practice
$631,938
General expenses
Motor vehicle costs
$40,000
3 doctors vehicle and 1 practice manager
Motor vehicle allowance
$16,500
1 doctor
Housing allowances
$55,000
Property Rentals
$30,000
4 doctors
3 buildings Triabunna, Bicheno &
Swansea
Electricity
$12,000
3 buildings
Telecommunications
$10,000
4 practices
Computer costs
$6,000
Stationery & Postage
$2,900
Medical consumables
$20,000
Advertising
Depreciation
Bank charges
$1,000
$40,000
$300
Accountancy, audit fees & legal costs
$10,000
General materials
Repairs and maintenance, buildings &
equipment
$8,000
$2000 per practice
$6,000
Insurance: property & public liability
$10,000
Cleaning
$60,000
Sub total general expenses
$5,000 per practice 4 practices
$327,700
Total operating costs
$1,041,638
Operational shortfall
-$271,638
3 buildings
East Coast Health Review August 2013
21
Observations on questions from the terms of reference
Is the Council vision for managing health services in the municipality now possible?
It does not seem so for the following reasons:
• Not all medical practices want to participate. It would only serve Dr. Naidooʼs practice if formed.
• Economic viability is challenging.
• There is dissension and distrust between Council and Dr.Naidoo.
• There is tension between the East Coast Health Committee and Council.
• Dr. Naidoo will probably not agree to any structure where Council has control.
Should Council be involved in providing support for medical and health services and to what extent?
• It is within the role of Council to become involved in medical services.
• It is not unusual for Councils in rural and remote areas to become involved in attracting medical and health
services.
• Glamorgan Spring Bay Council has shown leadership in providing a new medical centre and equipment in
Triabunna and incentives to doctors. The incentive program has required a service charge on properties. It
also provides facilities to the Bicheno practice.
• The decision to implement a Practice Management Service Agreement with two practices may in the long
run prove onerous for Councilʼs administration. Glamorgan Spring Bay Council is a small organisation with
limited resources.
• The extent of councilʼs involvement in medical services may not be apparent to the community and the
costs are not as visible as they could be.
• It is a concern that no lease exists with medical practices occupying council property.
If it is possible to establish a community based and managed entity to manage health services what
structural model is appropriate?
Two options seem appropriate
• A Single Authority of Council established under the Local Government Act.
• An Incorporated Association established under the Associations Incorporations Act 1964
• Both options require considerable work and commitment to establish.
• There is also the possibility that the community, when consulted, might not support the formation of a
Single Authority by Council.
• The community, under its own initiative, could organise an incorporated association without involving
Council.
Would a separate entity be sustainable and financially viable?
• Calculations indicate neither option appears financially viable without increasing the Medical Service
Charge and the contribution made by doctors. It would also need to include all practices.
Is there sufficient capacity in the community to manage a separate entity?
• There are talented people in the community but sustainability factors are not fully evident.
• The age profile of the community could influence the availability of people to commit the time and effort
needed.
What are the benefits to Council of transferring assets relevant to East Coast Health to a separate
legal entity?
• The assets have been purchased using Community funds. Council is the custodian of those assets whilst
they remain in public ownership.
• Transferring them, at no cost, to a separate legal entity is risky if the entity ceases to exist or is sold. There
is also the risk that the assets would not be cared for.
• Selling the assets for a market price and reinvesting the community funds into public goods would be an
option to consider if the opportunity arose.
• If a separate entity is formed then Council should retain ownership of the assets and lease them to the
entity. Ideally the lease terms should be commercial. In the interests of transparency any contribution
toward the lease costs by Council should the subject of a separate decision. In this way the value of the
contribution will be known. Also the contribution can be varied if conditions change.
East Coast Health Review August 2013
22
What are the benefits to Council of removing its current management and oversight responsibilities?
• Property ownership and maintenance are normal activities for a Council so there is no real benefit
achieved by removal.
• Practice management and administration may prove onerous over time. Councils do not usually provide
these services. Given the size of Council it could be beneficial to find another way to do this work.
Are the operations of the facility sufficiently complex and burdensome on Council to justify the
creation of a new body corporate?
• This might be the case if all practices signed up to the Practice Management Agreement.
• Property maintenance should not be complex or burdensome. Council currently maintains a range of
properties.
Whether the current committee or community members are going to want to take on the responsibility
of administering a body corporate?
• The rhetoric suggests support for a community-based entity.
• It is doubtful that people understand the work and responsibility required.
• The community can, on its own, move to form an incorporated association.
What level of autonomy does Council want East Coast Health to have over its operations?
• Actions to date indicate that Council is apprehensive about giving East Coast Health full autonomy.
• The initial vision was for a Council owned company.
What are the significant benefits to be gained by Council that justify taking steps to create an
independent body, which must be administered according to legislation and rules?
• Under the current circumstances the benefits are not clear.
• If there is no economic viability then there is no benefit.
East Coast Health Review August 2013
23
Appendix 1: Summary of background documents and history
•
Initially the site of the Community Health Centre in Triabunna housed a local hospital, which was run by
the State Government. It offered a range of services from births to geriatrics. It was also the pharmacy.
Difficulty was experienced recruiting registrars so around 1966 the government encouraged the
development of a private medical practice by offering incentives like access to nurses, rent free premises
and cost free supply of consumables.
•
A number of doctors came and went and Dr. Pranesh Naidoo bought the practice in the 1990ʼs from Dr.
Marcel Burkhout. He received rent-free premises, access to nursing services and free consumables but
there was no documentation of the arrangements. He has practiced in the area since that time.
•
In 2005 Beth Wyllie, Dr. Naidooʼs Practice Manager, wrote to Council about the difficulty of accessing
locum services in rural areas.
•
In 2007 the then General Manager of Council wrote to Dr. Naidoo expressing concern about community
access to medical services. He indicated that there was scope to increase the number of doctors at the
centre. Dr. Naidoo was asked to indicate his thoughts and his plans for the future. Community members
unable to access services from Dr. Naidooʼs practice were travelling to Swansea, Sorrel and Brighton.
•
In September 2008 David Metcalf, the new Council General Manager, wrote to Dr. Naidoo about
transferring title to the land on which the State owned Health Centre was situated to the State
Government. Council had been advocating for the building to be extended to accommodate additional
medical services. Council also attempted to obtain ownership of the building, as they were reluctant to
invest in an asset they did not own. The State Government did not agree to transfer the building to Council
so the impasse was resolved by transferring the title for the site to the State Government. The transfer
allowed the State to extend the premises to accommodate ambulance and paramedic services. The letter
indicated that the State Government would probably want to document occupancy arrangements for Dr.
Naidooʼs practice and Council was lobbying to have a medical practice continue operating from the site.
•
Around this time the Health Department, in response to budgetary pressure, began reviewing
arrangements with doctors operating out of Community Health Centres. Arrangements regarding the use
of nursing services began to change causing tensions and uncertainty. Dr. Naidoo wanted more certainty
about future arrangements and raised the idea of a community-based model with a number of his patients
and an informal group began meeting with him to discuss the concept.
•
In December 2008 David Metcalf wrote to Dr. Naidoo advising that Council would provide $6,000 to assist
with cost of a locum to cover a period of leave in December 2008 and January 2009. In December 2009
David Metcalf wrote to Dr Naidoo advising that Council would provide $13,000 to assist with locum costs
for two periods of leave in 2010. This seems to be the beginning of monetary assistance to doctors by
Council.
•
22/12/2009 Council endorsed the original concept of East Coast Health.
•
Community dissatisfaction with government changes increased around 2010 and a public meeting was
called. The Health Minister Lara Giddings established a community based health consultative committee.
This included Council, school, service clubs and community representatives. The committee operated for
about 18 months but eventually lapsed due to lack of government support and interest.
•
Rivers, a professional practice support company, was retained to help with doctor shortages in Bicheno
and Swansea. Council introduced a rate levy for the Northern section of the municipality to provide an
incentive package for doctors (unsure of the specific date). This created equity tensions with Dr.Naidoo.
•
On the16/3/2010 David Metcalf wrote to Dr. Naidoo referring to a meeting on 9/2/2010 about the arrival of
a new doctor for Triabunna. It raised the conditions being provided to Dr. Winston Johnson who had been
recruited from the West Coast of Tasmania. The letter said it was expected that Council would extend
st
equal benefits to all doctors across the municipality by the 1 of July 2010. It explained that Council would
provide administrative services to Dr. Johnson funded by 25% of Dr. Johnsonʼs patient income. An interim
arrangement was proposed for Council to pay Dr. Naidooʼs practice 50% of wages and IT costs so that Dr.
Johnson could share these resources. Negotiations were underway with Beth Wyllie to assist Dr Johnson
settle in and put IT and administration arrangements in place to enable all practices in the municipality to
East Coast Health Review August 2013
24
switch to Council provided administration services. It also stated that Council has secured a contract to
buy the Forestry building in Triabunna and invited Dr. Naidoo to attend an inspection of the site prior to
works commencing.
•
•
•
18/3/2010 Letter from David Metcalf to Medicare Australia seeking a Medicare number for Dr. Johnson.
1/4/2010 Letter from DHHS Executive Director Primary Health (Peter Lorraine) referring to a meeting on
March 29 2010 confirming arrangements for 6 months temporary accommodation of Dr. Johnson at the
Spring Bay Community Health Centre.
In April 2010 Dr. Winston Johnson commenced practicing at the Community Health Centre sharing
facilities and staff with Dr. Naidoo.
•
27/4/2010 Council decided to establish a section 24 Special Committee East Coast Health Municipal
Committee and to call for expressions of interest from the community. The Council item foreshadowed that
the committee could become the board of the proposed health company if Council chose to move in that
direction. The committee was to ideally have 12 members including:
o Councilʼs General Manager
o Two Councillors
o Practice Manager
o Eight other invited community members
o Doctors free to attend any meeting
•
From 2009 through 2010 a paper was progressively developed by Councilʼs General Manager David
Metcalf outlining “A vision to form a self funding / self supported health company on the East Coast of
Tasmania in the Glamorgan Spring Bay Municipality wholly owned by the Glamorgan Spring Bay Council.”
The purpose of the company East Coast Health & Community Services Ltd being to promote optimum
health outcomes and well being in the Community. The wholly owned Council Company would have a
CEO and a board of eleven directors and have its accounts consolidated into Councilʼs operating results.
Three scenarios for professionals to interact with the company and a capped fee of 25% of income were
proposed. The paper outlined why the company was needed and described the anticipated key results,
outcomes and measures. It foreshadowed the development of a business plan, risk analysis and a levy on
rateable properties.
•
An advertisement was placed in the Mercury newspaper seeking interested persons to form an East Coast
Health Committee and interviews were conducted six months later.
•
24/6/2010 Letter from D Metcalf to Dr. Naidoo. (Similar letter sent to Dr. Johnson) Stated the initial plan
was to have the administration of Dr. Naidooʼs and Dr. Johnsonʼs practices transferred to Council by July 1
2010. This date was extended to 1/10/2010. The transfer did not take place because Dr. Naidoo wanted
the committee in place before any transfer of staff would occur. In the meantime Council engaged a
practice manager, which both doctors were using with the full cost being carried by Council. Carrying 50%
of the staff and admin costs and the wage for the practice manager cannot continue past 1/7/2011.
Council still prepared to employ the practice staff so long as doctors contribute 25% of earnings to pay for
this service. Doctor Naidoo was asked to indicate his intentions for the new financial year
•
June 2011 Terms of reference drafted for a section 24 (Local Government Act) Special Committee of
Council. It was called the Glamorgan Spring Bay Council East Coast Health Municipal Committee
ECHMC. Under the Local Government Act Council may appoint a special committee for such purposes as
it thinks fit. It can also appoint whom it wants onto a special committee and determine its procedures.
Committees of this nature are usually formed to help Councils carry out their responsibilities. The terms of
reference provided a number of objectives and actions for the Committee to consider and advise Council
in the area of Health Services for the municipality. Some of the objectives were broad and some specific.
However the committeeʼs role was limited to being a community advocate providing advice and
recommendations to Council. The committee was not given authority to implement actions in areas where
Council management had responsibility and no financial responsibility was delegated. Council was
nominated to provide administrative support to the committee. Committee members were to receive
reasonable out of pocket expenses for attending monthly meetings. The committee was required to report
to Council after each meeting and prepare an annual report. Details like membership; office bearers and
meeting procedures were also detailed.
The terms of reference contained an objective for the committee to develop an agreed Medical Centre
Model including governance, building infrastructure and location.
East Coast Health Review August 2013
25
The terms of reference also stated that the ECHMC would assist council officers with the following
operational matters:
o Oversee and approve the strategic direction, financial accountabilities, resource management,
compliance and operational management of medical centre
o Recruit and select staff including the practice manager, nurses and support staff
o Oversee the provision of administrative services including the requirements of accreditation
o Structure a remuneration package for medical staff
o Create locum network with financial subsidy, transport and accommodation
o Provide continuing support for the families of medical staff
o Develop strategies to attract, retain and plan for succession of medical staff
o Develop strategies to support education of registrars and students
Note: The ECHMC would need operational resources and a close working relationship with Council to
perform these tasks. Also the tasks take the role of the ECHMC beyond that of advice and advocacy. They
seem to be describing the work that would be done by a practice management company. A section 24
committee, without resources or delegated authority, is not the appropriate vehicle to do this work.
•
6/7/2011 letter from D Metcalf to Doctors Naidoo and Johnson in response to their letter of July 5 2011
o Agreed the new administration structure should be formalised. Advised there was no way to “lock
in” future councils to the agreement
o An answer on buildings will be coming from DHHS by the middle of July. If an exchange of
buildings is not possible the committee will need to consider the alternative Edwards proposal
involving the call centre building. Suggests that investor returns would make this option
unaffordable.
o Aims to call a meeting of the steering committee after July to discuss terms of reference, transfer
of administration, buildings, election of chair and minute taking
•
5/12/2011 letter to Dr. Naidoo from David Metcalf. Refers to letter from Doctor Naidoo of 23/11/2011 about
a contract to continue providing administrative services to Dr. Johnson at the Spring Bay Medical Centre.
States that Council agrees in the short term to:
o Pay 50% of admin costs up to 2/3/2012 when the agreement will need to be renegotiated. These
costs will then be recovered from Dr. Johnson
o Admin costs to include wages (clerical & nursing), medical consumables and IT support
o Council to pay no later than 14 days from receipt of invoice
o Invoices to contain detail of services provided
o Council will not be involved in any disputed charges levied on Dr. Johnson as a result of paying
Dr. Naidoo. These are to be sorted out between the doctors
o Outstanding invoices dating back to July 2011 have been authorised for payment
•
13/12/2011 East Coast Health Summary Paper prepared by Jill Morgan the Chair of ECHMC provided
background to formation of the ECHMC and gave progress to date:
o Committee approves establishment of a medical centre at the old Forestry building and approval
processes were underway.
o Draft practice management contracts detailing the level of support for GPʼs and financial
arrangements with Council have been prepared for review by the ECHMC and doctors. Envisages
a contribution by doctors of 25% of income to Council
o Indicates the transfer of current Triabunna medical centre staff to be formalised in near future and
that Council will be the initial employer.
o When the management contracts are signed the appointment of a practice manager will be made
in early 2012.
o Details a newsletter item to be circulated to the community through council processes
o Foreshadows work commencing in 2012 on the establishment of an incorporated association to
take over control of East Coast Health including administration and property. Details legal advice
on considerations council should make regarding the transfer of assets and the level of autonomy
for the body.
•
During the first half of 2012 work began refitting the Forestry building
•
7/2/2012 Minutes of ECHMC significant items included:
o Management contracts to be reviewed.
o Terms of reference for the committee accepted.
East Coast Health Review August 2013
o
o
o
26
Committee to be renamed East Coast Health Committee.
Acceptance of building plans.
Agreed to advertise practice manager role (rejected an expression of interest by May Shaw to
undertake these services)
•
20/3/2012 Minutes of the ECHMC significant items included:
o Final draft of management contracts presented. Comments to be provided by 23/3/2012.
o Position description for the practice manager role accepted.
o Building works to be substantially completed by late April.
•
17/4/2012 Minutes of the ECHMC significant items included:
o Equipment list for the new centre.
o No changes to management contracts received from doctors. General Manager of Council to
issue new documents a.s.a.p.
o Deferred recruitment of the practice manager role as IPN had withdrawn from Bicheno and
Swansea. Decided to formally ask doctors in Swansea and Bicheno to join the committee.
o Doctors to liaise with Council GM on furniture and fittings for new building.
•
8/5/2012 Minutes of the ECHMC significant items included:
o Equipment transfer from DHHS
o Governance recommendation from Committee to go to next council meeting.
o Swansea doctor declined to join committee. Bicheno doctor undecided.
o Anticipate doctors moving into the new centre from July 2nd 2012.
o Management contracts accepted by the committee.
o Suggested that previous practice manager be approached to help with transition.
o Practice manager role to be advertised at 22.5 hours pw if Bicheno included or 15 hours pw if
Bicheno not involved.
o Council GM arranging IT installation.
•
2/7/2012 Doctors Winston Johnson and Vane Tempest signed the management contract agreement for
Council to provide administrative services.
•
9/7/2012 Minutes of the ECHMC significant items included:
o All doctors happy with management contracts, final copies to be provided
o Practice manager and cleaner positions being shortlisted
o All Bicheno staff transferred to Council on contracts. Triabunna yet to determine entitlements.
o Move to be within two weeks; equipment and IT being finalized
•
Late July / August 2012 Doctors Naidoo and Johnson moved into the new building. Dr. Naidoo had not
signed the management contract but Council anticipated he would do so.
•
30/7/2012 Philip Pyke was employed on a permanent part time contract to be the practice manager for
Doctors Naidoo and Johnson. Hours to be 15 per week with the ability to work additional authorised hours.
The intention was to have the position also cover the Bicheno practice at some point in the future.
•
1/8/2012 email from D. Metcalf to P. Pyke about the proposal under the management services contract
that doctors pay 100% of income to Council and receive 75% back. The email offered an alternative
approach:
o Doctors can bank their income where they like.
o Cleaner and the practice manger will continue to be paid by Council.
o 100% of the cleaner cost will be charged back to Doctors Naidoo and Johnson.
o 2/3 of the practice manager cost will be charged back to Doctors Naidoo and Johnson and 1/3 to
Bicheno.
o Alternatively Council will cease to employ the cleaner and the practice manager and Doctors
Naidoo and Johnson can employ them. All expenses of the practice will be paid by both doctors
and Council will supply the building only. All other expenses incurred by Council to be also directly
billed.
o All expenses are paid by Council including wages and and a monthly reconciliation is attached to
an account sent to the doctors.
o Would be equally happy for Council just to supply the buildings.
East Coast Health Review August 2013
27
•
15/8/2012 Letter from Jill Morgan Chair of ECHC to D. Metcalf GM GSB Council: She acknowledges the
support of Council in the establishment of the East Coast Health Centre but raises the following concerns.
o The intention to establish an incorporated association or a company fully owned by Council. Urges for
this to happen so the centre can operate as a separate entity, minimising GMʼs workload and enabling
the Practice Manager to manage and report to the new entity.
o In April 2012 asked for a meeting with Councils solicitor to progress the formation of the entity. Was
then asked to attend a workshop with councillors and made arrangements to do so. Told a few days
prior not to worry, as there would not be time. Found this offhand and less than professional.
o Hours of Practice Manager insufficient to establish Triabunna and manage Bicheno. Proposes an
increase to at least 25 hours per week.
o Original understanding was that doctors would contribute 25% of earnings to cover the practice
manager, nurse, reception, cleaner, consumables, maintenance and accreditation costs. The funds
were to be deposited in a Council bank account for the centre.
o If funds were not sufficient this is to be discussed as a matter of urgency. Financial modeling was
done in 2011
o Doctors Naidoo and Johnson have agreed that 25% of centre income will be deposited in the Centre
account from August 1. They will cover salary for pay period August 1-3 and will invoice council.
Understood that Dr. Vane – Tempest agreed to commence on July 1.
o There will be opportunities to increase income through attracting allied health practitioners who will
also contribute 25%. There is a physio interested in working from the centre 2-3 days pw
o The practice manager needs to access the bank account for minor expenditure. The practice manager
reports to the committee once a month.
o Proposes that the entitlements of existing staff will be minimal and council should waive the transfer of
funds as a good will gesture. Asks for employment contracts to be forwarded to staff a.s.a.p. and that
salaries and conditions remain the same.
o Raises concerns about storing patient data on Council server. Data is confidential and belongs to
doctors. A potential issue for accreditation.
o Suggests that these matters may not have been given sufficient prior consideration. Asks that they be
considered now.
•
28/8/2012 Glamorgan Spring Bay Council minutes: The letter from Jill Morgan and a number of emails
tabled for discussion. Decision – the general manager write to Dr. Naidoo advising him he has 7 days to
sign the practice agreement and agree to a satisfactory staffing level based on the 25% fee to Council,
which has been agreed with the committee over several meetings.
31/8/2012 Letter to Dr. Naidoo from D Metcalf. Advising that Council had moved that Dr. Naidoo should
advise his intentions concerning the signing of the services contract and contributing 25% of income to
East Coast Health so administration of the new centre and associated arrangements can settle down.
Deadline of 11/9/2012 given.
•
•
11/9/2012 Letter from Dr. Naidoo to Glamorgan Spring Bay Councillors and the General Manager in
response to Councils letter of 31/8/2012. Makes the following points.
o The generic services contract has been implemented “imposed in a draconian fashion by Council”.
o The service contract and the administrative responsibilities of East Coast Health have not been
negotiated with ECHC in an open and transparent manner.
o Resolution of issues should be through the legally constituted ECHC on which Council has
representation.
o Do not need to deal with issues through a mediator (sec 6.2 of the Committees terms of
reference). Can resolve matters by negotiation with a spirit of goodwill, mutual trust, respect and
cooperation.
o Requests councillors to work through ECHC to form an independent incorporated association –
the preferred model for administration of the new medical practice.
o The community by paying the medical levy imposed on them by Council are ultimately
shareholders of the new medical practice / administration
o Collective motivations must be honorable not driven by ego, self-interest, power, control or
domination. I have given up all of my freedom and autonomy by gifting my thriving medical
practice to the community. I have thrown all my support and invested all my energy behind the
ECHC. Asks for Council to do the same
o The ambition is to create a unique, high class, fully functional, robust democratic and independent
Community Health Board / incorporated association that will best represent the needs of our
East Coast Health Review August 2013
o
o
o
28
community into the future. The structure will underpin the provision of high quality, viable and
sustainable health care service delivery.
Safeguards are needed to protect the community asset from the vagaries of any future council or
amalgamation or from being handed over to commercial medical operators like IPN
No other model for practice administration is acceptable to me.
All I wish to leave behind is a legacy that I have done my work
•
25/9/2012 Council decision: Council advises the Chair of ECHC that a dispute exists between Dr Naidoo
and the Council and that the matter should be resolved in accordance with section 6.2 of the terms of
reference. That Council through the general Manager will nominate an independent negotiator to help
resolve the dispute. The decision reached to be binding on all parties.
•
9/10/2012 Minutes from ECHC meeting significant items included:
o P Pyke welcomed to first meeting
o Admin staff still waiting for contracts from Council
o Concerns expressed about security of patient information under the IT system
o Practice manager has no access to Councils financial system
o 15 hours pw not enough to do the work
o Moved the following motions. That the IT data storage matter is addressed as a matter of urgency.
The Practice Managerʼs hours be increased to 22.5 hours pw. The original model of Governance –
the establishment of a separate entity to oversee East Coast Health on behalf of the Glamorgan
Spring Bay Council be reinstated and progressed as a matter of urgency
•
24/10/2012 Letter from David Metcalf to Dr. Naidoo as a follow up to letter of 26/9/2012. Advises Council is
in dispute with Dr Naidoo and that Alan Daley has been appointed as a mediator. Requests times to meet.
•
24/10/2012 Letter from David Metcalf to Jill Morgan Chair ECH Committee about ECHC motions
considered at Council meeting on 23/10/12
o IT data storage be addressed as a matter of urgency (Passed)
o Practice managers hours are increased to 22.5 hours pw a.s.a.p. (Lost)
o The original model of governance the establishment of a separate entity to oversee ECH on behalf
of GSB Council be reinstated and progressed as a matter of urgency (Lost)
•
1/11/2012 Letter from David Metcalf to Jill Morgan in response to her letter of 15/8/2012: key points were:
o East Coast Health cannot operate as a separate entity from Council due to the fact that Council is
responsible for the funding of costs
o Any CEO of ECH would be responsible to the Council GM and the board to protect ratepayers
funds
o With the current unstable process there is no way he (David) would sanction a separate company
o Talks of comments that do nothing for cooperation and which are destabalising
o The workshop with Council was in the middle of budget setting. Does not see the matter as
urgent. Does not want council or management to be forced into a situation when they are
uncomfortable about the process.
o Not enough funds in the budget to increase hours of the practice manager. Has instructed the
practice manager to cease involvement with Bicheno
o Payments over 7 fortnights have exceeded budgeted hours and have included overtime payments
that have been authorised by one doctor and not by GM of council. Average has been 54 hours
per fortnight.
o Maintains that 25% should be adequate if practice operates within guidelines. Costings were
based on staffing levels provided by Beth Wyllie and financial details have been given to the
committee.
o The payment arrangements proposed for the doctors were not discussed with Council or the
committee and are contrary to agreements signed by doctors Vane-Tempest and Johnson and
which Dr. Naidoo agreed to sign.
o Agrees that allied health professionals can bring in additional income. Queries what arrangements
have been made with professionals working from the centre and who did the negotiations.
o No discussion with Council or the committee about the practice manager accessing the bank
account. Council and the General Manager are responsible for money handling decisions.
o Wants information about staff entitlements before issuing contracts. Quotes minutes of ECHC that
indicate staff do want to be employed by Council. If Council set up a corporate structure, the
East Coast Health Review August 2013
o
o
o
o
o
o
o
o
29
employees would end up council employees. Suggests Council has demonstrated enough
goodwill to date.
IT practice data back up similar to what is done by companies like IPN.
Refers to letter of September 3 and reinforces that:
§ The administrator is defined in the contract agreed to by the doctors
§ Accounting principles are set up and administered by Council and this has been
communicated to the committee
§ The committee terms of reference does not give control to the committee.
§ The committee makes suggestions and council considers the advice
nd
Refers to letter 2 November about Councilʼs decision to employ Practice Manager for 15 hours
as being unjust. States that P. Pyke is an employee of Council and Council has decided not to
increase hours. States the GM of council is the GM of East Coast Health. Two doctors are
contracted to ECH for administration purposes and run their practices under this banner
Vision for ECH remains a coordinated health delivery services organisation for the GSBC area
where all doctors work together and are supported by Council offering administration services.
Feels that under current circumstances this cannot work.
Proposes to maintain arrangements where Council pays for half of Doctor Naidooʼs staff and
Doctor Naidoo pays half the salary of the Practice Manager and half the costs of consumables.
This arrangement protects the interests of Doctors Johnson and Vane Tempest and allows Dr.
Naidoo to control his portion of the business.
Alternatively the Practice Manager could be terminated and reemployed by Dr.Naidoo. Then half
the wages of this position and other staff can be charged to Council. Council continues to provide
building and cleaning costs.
Suggest that Councilʼs willingness has been undermined by the Committee wanting to run the
operation in the way it sees fit without reference to Council or other doctors.
Reinforces the Committees advisory role.
•
4/3/2013 Minutes of ECHC main points included:
o Data storage: Dr.Naidoo has removed his patient records from the Council server as they were
transferred without discussion with him
o Medical centre staff contracts had not been transferred to East Coast Health
o Difficult to perform the duties of Practice Manager in 15 hours pw
o Accreditation for Bicheno and Triabunna
o Governance model for East Coast Health that oversees two medical practices and possibly a
third. A model to be recommended to Council with the general manager of GSB Council as the
company secretary and Council as the primary shareholder with a board
o Complaints about the phone system not handling queues of callers
o Concerns about doctor at Bicheno causing problems with IT system through actioning patients in
Triabunna by accident.
o Physiotherapist John Larkin moving to the area and interested in operating out of the centre
•
7/5/2013 Letter from D. Metcalf to Dr. Naidoo about outstanding invoices. Key points:
o Three invoices amounting to $16,520.80 relating to 50% of the expenses incurred with ECH
o Asks for a response by 17/5/2013 as to when invoices will be paid or reasons for dispute over
payment
o Advises that in the absence of a response that deductions will be made for accounts owing to the
Spring Bay Medical Centre or The Naidoo Family Trust
o If further information needed then contact GM
•
Late May (no date on letter) Letter to Dr. Naidoo concerning letter of the 7 of May.
Key points:
o Advises no response received to letter of 7/5/2013 which requested a response by 17/5/2013
o Details amounts and invoices outstanding
o Details deductions from invoices owing to Spring Bay of $12,491.07 leaving a balance of
$4,029.73
o Advises deductions will continue until full amount paid
o Offers to discuss
•
8/6/2013 Advertisement placed in the Mercury newspaper for a receptionist to assist Dr. Johnson.
th
East Coast Health Review August 2013
•
•
•
•
•
•
•
30
25/6/2013 email from P. Pyke to D. Metcalf seeking confirmation for telephone directory advertisement for
East Coast Health. The advertisement made no mention of Dr. Johnson only Dr. Naidoo and states that
East Coast Health was formerly known as the Spring Bay Medical Centre.
June 2013 Legal action between Dr.Naidoo and Council commences over the invoices and the
advertisement for a receptionist to help Dr. Johnson.
1/7/2013 R. Campbell from groupwork pty ltd asked by D. Metcalf (on behalf of the ECH governance
group) to undertake an independent review of East Coast Health.
3/7/2013 Email from Jill Morgan to R. Campbell providing terms of reference and associated information.
7/7/2013 Email from Jill Morgan to R. Campbell suggesting additional people to meet and interview.
1/8/2013 Email from P. Pyke advising an immediate change to surgery opening hours. This decision was
not discussed with Council as building owner. Reason for the change not explained and not apparent that
Dr. Johnson had been consulted.
2/8/2013 Email from Jill Morgan to R. Campbell providing copies of emails about the IT arrangements at
Bicheno and expressing concerns about mismanagement.
East Coast Health Review August 2013
31
Appendix 2: The Medical Practice Management Agreement
A summary of the medical practice agreement is set out below. The summary is provided to show the nature
of the agreement. It is not a detailed interpretation of the document and should not be used for that purpose.
• The agreement is between Glamorgan Spring Bay Council and the Doctor. (All doctors have separate
practices)
• The doctor appoints council as the exclusive agent for practice services, for a term and a cost.
• Council has no control over the provision of medical services. There is no provision in the agreement to
regulate patient loads or working hours.
• Council is responsible for:
o Providing an office (building) to conduct the medical practice.
o The supply and installation of plant and equipment on the advice of the doctor.
o Costs of repairs and maintenance of the building, plant and equipment.
o Supplying medical, office and other materials including printing, stationery, forms, postage and
photocopying.
o The doctor being responsible for ordering and maintaining an inventory of medical supplies.
o Coordinating licences and permits
o Assisting the doctor achieve quality assurance and risk management processes
o Permitting the doctor to use the name East Coast Health and its associated logos. (The name and
associated logos are the property of Council)
o Advertising and marketing materials
o Procuring, employing, training and providing personnel to work at the practice.
o Managing the remuneration of practice personnel
o Maintaining employee records
o Providing billing and collection services
o Maintaining accounts and banking
o Budgeting
o Accounting procedures
o Maintaining a medical record system
• The doctor is responsible for:
o Providing medical (clinical) services.
o Maintaining professional standards.
o Scheduling medical services and maintaining availability.
o Indemnifying Council against any acts or omissions arising from the delivery of medical services.
o Maintaining doctors insurances
• Council draws a management fee for the delivery of practice management insurances. The fee being 25%
of the doctors patient income
•
Council pays a doctors fee. This includes rental assistance and vehicle benefits
• The agreement also contains provisions for termination, renewal and dispute resolution
• The Council and the doctors are independent contractors and not bound by employment or any other
arrangement. Doctors are able to work for third parties if there is no conflict of interest.
Disclaimer
Unfortunately in todayʼs litigious world it is essential to state and for all parties and readers to understand that
the information contained in this report is provided in good faith and is derived from sources believed to be
accurate. Groupwork pty ltd (trading as Campbell&Jones) does not give any representation or warranty as to
the reliability, accuracy or completeness of the information, nor does it accept any responsibility arising in any
way (including by negligence) for errors in, or omissions from, the information.
Report completed September 12, 2013