Public hearing 10, Sydney - Day 1

OPENING STATEMENT BY CHAIR

CHAIR:  Good morning, everyone.  Last week the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability held its ninth Public Hearing in which we examined the pathways and barriers to open employment with people with disability.  This week, with barely time to catch our breath, a similar but not identical cast returns to conduct the Royal Commission's tenth Public Hearing which will be the last for this tumultuous year 2020.  The subject matter of the hearing this week is the education and training of health professionals for the care and treatment of people with disability.  The hearing this week will be for two days only.

For the first time since February 2020, nearly 10 months ago, the three Commissioners sitting or participating in this hearing are all located in the one hearing room at the Commission's premises in Sydney.

I therefore commence by acknowledging the Gadigal people of the Eora Nation, the tradition natural custodians on the land upon which we meet.  I pay my respects to their Elders past, present and emerging, as well as to all First Nations who may be viewing this hearing on the live stream.

I am joined at this hearing by Commissioner Atkinson to my left and Commissioner Bennett to my right.

We are also joined in the hearing room by Senior Counsel Assisting the Royal Commission Ms Kate Eastman SC who appears with Ms Georgina Wright, Counsel.  Unfortunately, we have not yet reached the point at which members of the public can observe this hearing from the hearing room itself.

However, with all of the Public Hearings that we have conducted since the on set of the COVID 19 pandemic, the proceedings will be live streamed and can be viewed of course on the Royal Commission's website.

In the opening to Public Hearing 9, that was held very recently, I suggested that the Royal Commission's Interim Report which was tabled in the Australian Parliament on 30 October 2020 was well worth reading.  One reason for this suggestion was that the interim report draws on the Commission's Reports on earlier Public Hearings and identifies topics that are worthy of further consideration.  The main purpose of Public Hearing 4, which was held over nine days in February 2020, was to inquire into the quality of healthcare provided to people with cognitive disability.

As the Interim Report records, the Royal Commission found that although the Australian healthcare system compares well to systems in similar countries, it faces systemic challenges that adversely affect health outcomes for people with disability.  The Royal Commission also found that despite some worthwhile initiatives, there has been, and continue to be, systemic neglect of people with cognitive disability in the  
Australian health system.

The Royal Commission in the Interim Report identified a number of areas for further consideration.  These areas include how training and education of health professionals, medical practitioners, dentists, nurses and allied health workers can be adapted and adjusted to produce better quality, and care and outcomes for people with cognitive disability.  Specifically, the Royal Commission foreshadowed a further hearing addressing the content of training relating to cognitive disability, training provided to people studying to be health professionals, or who are already qualified in a particular discipline, addressing also the extent to which training programs involve people with disability themselves, the effectiveness of education programs designed to improve communications between health professionals and people with disability and that are also designed to address the unconscious bias of some health professionals towards people with disability and the education needed to equip health professionals to avoid diagnostic overshadowing, a problem about which we heard a great deal in Public Hearing 4.

This hearing will provide an opportunity to examine some of these issues.  As Ms Eastman will explain, the hearing will have a different format than other Public Hearings we have conducted.  Most witnesses are either health professional, representatives of universities or of other educational institutions and professional bodies, including those that are responsible for the accreditation of health professionals.

For the most part, the witnesses will give their evidence in panels.  I want to acknowledge that we have been assisted by very detailed information provided by a very large number of organisations for which we are very grateful.

Yes, Ms Eastman.

OPENING STATEMENT BY MS EASTMAN

MS EASTMAN:  Good morning Commissioners.  I appear with Georgina Wright of counsel and are instructed by the Office of the Solicitor Assisting the Royal Commission.  We also acknowledge and pay our respects to the traditional custodians on the land on which we are meeting today.  We pay our respects to First Nations Elders, past, present and emerging as well as to all First Nations People following this Public Hearing.

At Public Hearing 4 in February this year, you examined healthcare and services provided to people with cognitive disability.  Commissioners, you will recall the term "cognitive disability" is often used as an umbrella term and includes people with intellectual disability, autism, acquired brain injury and dementia.  At Public Hearing 4 you heard that people with intellectual disability have a higher mortality rate compared to the general population.  You will recall that 1.8 per cent of  
Australians have an intellectual disability, and more than half a million Australians living with intellectual disability of which over 60 per cent experience profound or severe impairments in core activities of daily living.

The results of a study released in January 2019 which was before you in Public Hearing 4, followed almost 50,000 people with intellectual disability receiving disability services over a 10 year period.  That study revealed the following: people with intellectual disability will die before their peers and they will die 20 years before their peers without intellectual disability.

People with intellectual disability who had cancer were almost eight times more likely to die from that disease in a 10 year period compared to those in the group without cancer.  For people with intellectual disability, having a series risk of mental illness increased the risk of death by four times.

People with intellectual disability who presented at emergency departments at hospitals and then admitted to hospital had four times the increased likelihood of risk of death.

The high rates of mortality among people with intellectual disability and autistic populations is potentially avoidable.  You heard that the presence of co morbidities, as the medical professionals describe it, does not adequately explain why people with intellectual disability face a higher risk of death.  So why is that study important?  The Australian Institute of Health and Welfare says that:

.... death data is vital to measure a population's health.  It provides information on patterns of disease that cause death in population groups over time.  Examining death patterns can help explain differences and changes in health status, evaluate health strategies, and guide planning and policy making.

Commissioners, your report following Public Hearing 4 identified a number of factors that may contribute to these alarming findings.  Professor Julian Trollor told you that the rates for people with intellectual disability, of death, could be improved dramatically if public health policies were more focused on interventions and health practitioners were more attuned with the treatment of co morbidities.

In this respect, Professor Trollor told you that training in intellectual disability health care for health professionals at all stages, from medical school to specialist training, is crucial to equip the system to deal with multi morbidity.  However, an audit of 12 medical schools in Australia in 2014 revealed that the median time where compulsory disability content was taught to student was 2.5 hours, and this is in the context of a course that extended between five and six years.

Throughout Public Hearing 4 you heard from parents, family members, carers and people with cognitive disability, as well as advocates and experts about their perception that some health professionals did not have the knowledge, skills or attitude to provide quality care to people with cognitive disability.
 

Several witnesses expressed their views that these issues could be better addressed by education and training to eliminate the health inequities faced by people with cognitive disabilities.  The witnesses believed that health professionals need education and training to ensure that health decisions are not in formed by their perceptions, attitudes and assumptions about cognitive disability.  You may recall Kim Creevey told you this:

There needs to be a concerted effort to provide substantial training and education for all medical staff about unconscious bias and the impact that it might have on their decision making about treating a person with disability.

You heard that education and training should involve exposure with people with disability to challenge the attitudes and assumptions of health professionals.  People with cognitive disability told you they should be involved in the training and education of health professionals.  Professor Nicholas Lennox said education programs should be developed and delivered by people with intellectual disabilities and their families.  Professor Trollor said that as educators, people with intellectual disability can encourage attitudes and encourage young future doctors to develop skills in this area.

Problems with communication were identified by several witnesses at Public Hearing 4 as having a significant impact on access to quality health care for people with cognitive disability.  Several witnesses said education and training in communication is important to improve access to healthcare for people with cognitive disability.

Then there is a need to address the gaps in knowledge about cognitive disability to ensure health care needs are being met and correct diagnoses are being made.  Several parents told the Royal Commission that in their experience health professionals did not appear to have much knowledge about cognitive disability and this did not inspire trust that the health care needs of their children were being met.  They advocated for the need for health professionals to undertake compulsory training on autism and cognitive disability.

Several witnesses said that better education and training should be embedded at all levels of theoretical study and clinical practice, from undergraduate study to practical training to continuing professional development.  Appropriate education and training should apply to all in the health profession, from clerical and administrative staff to clinical professionals.

Also at Public Hearing 6 concerning the use of psychotropic medication for people with intellectual disability, you heard that up to 60 per cent of people with intellectual disability are prescribed psychotropic medication to manage what is described as "challenging behaviours", and approximately 30 members of this population have mental illness.  Dr Catherine Franklin told you there has been international concern about over prescription of psychotropic medication for least 30 years.
 

Professor Trollor and Dr Franklin's research found the rates of mental illness among people with intellectual disability was at least two and a half times higher than the general population and they said this is a significant concern that the mental illness is often undetected for people with an intellectual disability.

Dr Franklin told you about a study comparing Australian general practitioners' encounters between 2003 and 2012 with Australians with intellectual disability and how that compared to encounters with the general population.  This study found that people with intellectual disability were significantly less likely to receive preventative health medication and more likely to receive psychotropic medication compared to people without intellectual disability.  So the education and training of health professionals was also a feature of Public Hearing 6.

At Public Hearing 6 you also heard from Ms Paula McGowan.  She told you about the death of her son Oliver.  She said when Oliver was being treated by doctors and he was in the hospital, she believed that the doctors and clinicians were trained in autism and intellectual disability.  She believed that they knew more than her.  However, it became clear to her, following an inquest into Oliver's death, that there was no mandatory training for health professionals in relation to these issues.  So in October 2018, Ms McGowan took her petition to the UK parliament demanding that training on intellectual disability and autism be mandatory for all health and social care professionals also.

This petition ultimately led to the UK Government making a commitment in 2019 to introduce the Oliver McGowan Mandatory Training in Learning Disability and Autism for all health and social care staff.  The Oliver McGowan Training in Intellectual Disability and Autism is now being trialled in England, and the program will be evaluated before being rolled out nationally.

May I now turn to the approach that we will take in this hearing.  This is a short two day Public Hearing and it is being conducted to examine the education and training of health professionals in Australia.  That is, with respect to people with cognitive disability, not more broadly.

In the time available we will be unable to examine each and every area of the health profession, including all allied health professionals.

We acknowledge the importance of education and training in all areas of health, and for those involved in the delivery of health services in all settings, so, Commissioners, we are likely to ask you to consider additional day for this hearing or to conduct a roundtable in early 2021 so we can address the other health professionals, but we want to use the time available in these two days as efficiently as possible.

For this hearing, Counsel Assisting has prepared a series of propositions.  A copy is or will shortly be available on the Royal Commission's website.  The propositions for  
change are grouped into three main categories.  First, framework.  And we ask, through framework, what proposals in the development of standardised competency framework can guide the development of all reforms to education and training.

Secondly, we look at the fundamentals.  The fundamentals propose key content and procedural elements that should guide and inform all training and education.

Then, training phases, which sets out propositions specific to the stages of education and training.

We will examine the 11 propositions with the health practitioners, representatives from university, specialist and medical and training colleges and accreditation authorities.

The format of this hearing will be different from previous Public Hearing.  Our focus is deliberately on the people and institutions with responsibility for education and training of health professionals and who have the capacity to effect change.

Over the following two days, there will be six panels.  Each panel will examine particular propositions and ways of improving the education and training of health practitioners who treat and care for people with cognitive disability.  For each panel, Ms Wright and I will identify the specific propositions to be addressed by the particular panel.  We will then provide a summary of the evidence provided by the panelists in their detailed statements and accompanying material, and will also summarise the issues to be addressed.

Commissioners, before we start the discussion with the panelists, you will hear from a person with lived experience about their interaction with the health profession.  For some this will be revisiting evidence heard at Public Hearing 4, and for some panels you will hear from new witnesses.

We will conclude tomorrow afternoon with Professor Julian Trollor, who will provide his reflections on the propositions and discuss the steps necessary to address the systemic neglect identified in your report.

May I remind everybody of the protections that apply to witnesses who provide information or give evidence to the Royal Commission.

Commissioners, can I deal with two administrative matters.  The first is it may be convenient to tender the whole of the Tender Bundle in Tender Bundle A and Tender Bundle B.  The documents that will be used or referred to over the course of this hearing are provided in two parts: Tender Bundle Part A and Tender Bundle Part B.  Tender Bundle A comprises witnesses statements that have been provided in relation to this hearing as well as two video recordings that were prepared as evidence for this hearing.  You will find these documents behind Tabs 1 to 91 of the Tender Bundle marked A.

 
Commissioners, I tender these documents and ask that they be marked as Exhibits 10-1 through to 10-40.

CHAIR:  Thank you, that can be done.

EXHIBITS #10-1 TO #10-40   EXHIBITS IN TENDER BUNDLE A

MS EASTMAN:  Tender Bundle B is comprised of other documents that may be referred to during the evidence over these two days.  You will find these documents behind Tab 1 through to Tab 62 in Tender Bundle B.  I note some of these documents have been the subject of tender in earlier public hearings of this Royal Commission, so I will not ask you to mark those documents as exhibits again but you will be able to identify them clearly as they have been reproduced in Tender Bundle B.

So with the exception of those documents, could I ask that you receive into evidence the balance of the material in Tender Bundle B, and mark those Exhibits 10-41 to 10-87, and we will endeavour to provide and upload a list of the exhibits during the course of the day.

CHAIR:  Yes, that too can be done, thank you.

EXHIBITS #10-41 TO #10-87   EXHIBITS IN TENDER BUNDLE B

MS EASTMAN:  There are a number of parties who have sought and been granted leave to appear, and you may wish to take their appearances.

CHAIR:  Yes, we will take the appearances of parties who have been given leave to appear.  Not all those parties will be present today, but we will take the appearances from those that are, perhaps starting with the Commonwealth.

MS MUNRO:  May it please the Commission.  My name is Amy Munro and I appear on behalf of the Commonwealth.

CHAIR:  Thank you very much Ms Munro.  NSW?

(Inaudible).

CHAIR:  I think that was you, Ms Furness, it was a little bit garbled not because of anything you did, but because the sound was not very good, thank you.

Finally, today, I think, from Victoria.

 
MR CHESTERMAN:  Commissioners, my name is Scott Chesterman.  I appear on behalf of the State of Victoria with Rebecca Bedford.

CHAIR:  Thank you, Mr Chesterman.
There may be other parties that will announce appearances tomorrow.
.
MS EASTMAN:  Thank you, Commissioners.  We are going to ask you for a very short break to reconstitute the room here before we start with our first panel, so if we could break for 5 minutes.

CHAIR:  Yes, we will adjourn for 5 minutes.  Thank you.

ADJOURNED    [10.23 AM]

RESUMED    [10.26 AM]

CHAIR:  Yes, Ms Wright.

MS WRIGHT:  Thank you, Commissioner.  In the first panel this morning, the Royal Commission will hear evidence from Dr Jane Tracy who works for the Centre for Development Disability Health Victoria, Professor Gary Velan, Professor of Pathology and Senior Vice Dean in the Faculty of Medicine at the University of NSW, Professor Rosalind Bull, Associate Dean, Learning and Teaching at the University of Tasmania's College of Health and Medicine, and Professor Michelle Leech, who is Deputy Dean of Medicine at Monash University.

CHAIR:  Yes, thank you very much, Dr Tracy, Professor Velan, Professor Bull, Professor Leech, for coming to the Commission in various places to give evidence.  I will place on record that you have taken the oath or affirmation as the case may be already.

Yes, Ms Wright.

DR JANE TRACY

PROFESSOR GARY VELAN

PROFESSOR ROSALIND BULL

PROFESSOR MICHELLE LEECH
 

MS WRIGHT:  Yes, General Counsel at each university has leave to appear for each of the relevant university professors, and the witnesses have all provided a statement to the Royal Commission which are found in Tender Bundle A.

CHAIR:  Are there any further appearances to be announced for this panel?

MS WRIGHT:  I thought it would be sufficient if I --- I think these people are in the background, so to speak.

CHAIR:  Thank you.

MS WRIGHT:  This panel will focus on Propositions 2, 3 and 7.

Dr Jane Tracy has worked with children and adults with intellectual disabilities and their families and carers for over 28 years.  She is a general practitioner and leads educational activities at the Centre of Disability Health Victoria.  The Centre provides teaching to medical, dental, nursing and some allied health students at Victorian medical and health science schools, particularly at Monash University, and to a lesser extent at the University of Melbourne.

In her statement to the Royal Commission, Dr Tracy outlined the large variation in the amount of disability related content in the curricular of medical degrees in Australia.  One of her academic articles on this issue is found at Tab 41 of Tender Bundle B.

Dr Tracy says that where universities do teach about intellectual disability, it is mostly due to the efforts of individuals or champions who advocate for its inclusion.  Some medical schools are highly reliant on these champions.

She describes the efforts she and her Centre have made in trying to keep their place in health curriculum in Victoria.  In her words, it requires continual advocacy.  Dr Tracy considers this to be a fragile basis for education and training as it depends on individual energy, commitment and advocacy for the cause.

In her experience, the subject matter is easily lost when there are changes in staff or at the time of curricular reviews.

Commissioners, Dr Tracy's observations are supported by data from two national audits conducted in 1995 and 2014 of undergraduate medical and nursing degrees.  Those audits examined what and how student are taught in terms of intellectual disability, physical and mental health content.  It was found that in the 20 year period between audits, little progress had been made overall to address gaps in intellectual disability education for medical students and nursing the students.

For nursing schools, of 31 nursing schools which took part in the audit, 16 were not  
teaching any intellectual disability content at all.  Only five schools provided the opportunity for students to have direct contact with people with intellectual disability such as during clinics or group home visits.  Across eight medical schools audited in both 1995 and 2014, the number of relevant course units had fallen over the 20 years.  And there was a slight decrease in the median number of hours of intellectual disability content provided by each school.

Of 14 medical schools that took part in 2014 the majority offered less than six hours of compulsory teaching on intellectual disability content across the whole degree, and the content was mostly taught in paediatrics, general practice and psychiatry.

Both the University of NSW and Monash University, from whom we will hear in a moment, have provided statements to the Royal Commission about the content of their medicine degrees and also their nursing degrees in the case of Monash.  Their statements are to the effect that they already incorporate significant components related to cognitive disability in their programs.  Both state that it is not possible to continually add content without overloading students.

Professor Bull of the University of Tasmania has said a commitment of the Deans of medicine and nursing to improving graduate capabilities in working with people with disability is needed.  However, her college does not recommend the introduction of a single compulsory subject.  Her faculty considers that deep learning is best achieved over time by embedding content and assessment throughout the curriculum.

One issue to explore with this panel is how do universities determine that their existing curriculum for medicine, nursing and perhaps other relevant degrees, is adequate, but first, Commissioners, we are going to hear a very short extract reminding us of some evidence that was given by Kylie Scott at Public Hearing 4 in February.  If that could be played now.

[VIDEO RECORDING PLAYED]

MS EASTMAN:  So Kylie, going to the doctor doesn't worry you at all; is that right?

MS SCOTT:  That is right, yes.

MS EASTMAN:  But sometimes you need help to organise a suitable appointment and someone to go with you.

MS SCOTT:  Yes.

MS EASTMAN:  And then in the next paragraph, number 16, you say you need someone to go with you for medical check ups, to check when you are sick, when you need to talk to the doctor and when you need to know how well you are.  Is that the case?
 

MS SCOTT:  Yes.

MS EASTMAN:  And then in number 17 you tell the Royal Commission about a few things that work well for you when you go to the doctor.  Do you want to read out what you've said to the Royal Commission in your note at paragraph 17.

MS SCOTT:  Yes.

MS EASTMAN:  All right.  Let me know if you need a hand at all or you would like me to read part of it.

MS SCOTT:  Okay.

MS EASTMAN:  But could I ask you to read what you've written down in paragraph 17.

MS SCOTT:  Yes:

A few things that work well for me when I go to the doctor are: (a) having a medical report on my habits, my behaviour bits and pieces; (b) when doctors check the Council for Intellectual Disability, My Health Matters folder to know about my concerns, about my health background, check ups, or for general use; (c) when I am responsible for my own actions; (d) when someone comes.

MS EASTMAN:  So Kylie, turning over the page, you wanted to tell the Royal Commission about how important communication is; is that right?

MS SCOTT:  That is right.

MS EASTMAN:  And can I ask you to look at paragraph 24.  And you want to tell the Royal Commission that doctors need to communicate properly to people with intellectual
disability; is that right?

MS SCOTT:  Yes.

MS EASTMAN:  And for you, it helps when doctors ask you short questions in plain English, speak clearly and are patient.

MS SCOTT:  Yes.

MS EASTMAN:  And that helps you make decisions; is that right?
.
MS SCOTT:  That is right.

MS EASTMAN:  And you also say to the Royal Commission --- this is paragraph 25  
--- that doctors should talk to families:

If someone's child has Down syndrome, they can take it on board and see what's going on.

So that's your advice to the Royal Commission and to doctors about talking to families; is that right?

MS SCOTT:  Yes, definitely.

[VIDEO RECORDING ENDED]

MS WRIGHT:  We would leave that there.  Kylie would like everybody to know she has a new website at kyliedownsbarriers.com.au.

EXAMINATION IN CHIEF BY MS WRIGHT

MS WRIGHT:  Dr Tracy, I will start with you.  Your full name is Jane Tracy, is that right?

DR TRACY:  That is correct, yes.

MS WRIGHT:  You are a qualified general practitioner?

DR TRACY:  Yes.

MS WRIGHT:  You work at the Centre of Developmental Disability Health Victoria?

DR TRACY:  Yes, it is the Centre for Developmental Disability Health, Victoria, yes.

MS WRIGHT:  I apologise.  You currently lead the educational activities at the Centre?

DR TRACY:  That is correct, yes.

MS WRIGHT:  The Centre, along other things, delivers disability education and training to some medical and other health schools in Victoria.  Is that so?

DR TRACY:  Yes, we do.  Yes.

MS WRIGHT:  And you have some 28 years' experience in this work?
 

DR TRACY:  Yes, I do, yes, yes, absolutely.

MS WRIGHT:  I'll come back to you in a moment.

Professor Leech, your full name is Michelle Leech?

PROFESSOR LEECH:  That is correct.

MS WRIGHT:  You are the Deputy Dean (Medicine) of Monash University?

PROFESSOR LEECH:  Correct.

MS WRIGHT:  You oversee the delivery of Monash's medical programs across Victorian campuses and the Malaysia campus, is that right?

PROFESSOR LEECH:  That's right.

MS WRIGHT:  You are also the head of the Rheumatoid Arthritis Clinic at Monash Health, and a Fellow of the Royal Australasian College of Physicians?

PROFESSOR LEECH:  Yes, that is correct.

MS WRIGHT:  I will just note, you are also the current Vice President of Medical Deans Australia and New Zealand?

PROFESSOR LEECH:  That is right, correct.

MS WRIGHT:  Now Professor Bull, your name is Rosalind Margaret Bull?

PROFESSOR BULL:  Yes.

MS WRIGHT:  You are a Professor, and the Associate Dean (Learning and Teaching) in the College of Health and Medicine at the University of Tasmania?

PROFESSOR BULL:  That is right.

MS WRIGHT:  Your training is as a registered nurse?

PROFESSOR BULL:  Yes.

MS WRIGHT:  In the past, one of your roles has been as a senior advisor for accreditation with the accreditation authority for nurses, ANMAC?

PROFESSOR BULL:  Yes.

MS WRIGHT:  And at the University of Tasmania you are currently responsible as  
Associate Dean for the delivery of the Learning and Teaching Program at the College of Health and Medicine, is that so?

PROFESSOR BULL:  That is right.

MS WRIGHT:  And that takes in degrees in medicine and surgery, and the Bachelor of Nursing?

PROFESSOR BULL:  Yes, but it also ---

MR WRIGHT:  Sorry.

PROFESSOR BULL:  It also ---

MS WRIGHT:  And does it also include any allied health degrees?

PROFESSOR BULL:  Yes, pharmacy, psychology, paramedicine, we have quite a range of other courses in allied health coming on, from '22 onwards.  2022 onwards.

MS WRIGHT:  Thank you.

Professor Gary Velan you are a Profession of Pathology at the University of NSW, is that so?

PROFESSOR VELAN:  That is so.

MS WRIGHT:  And the Vice Dean (Education) at the Faculty of Medicine at the University of NSW?

PROFESSOR VELAN:  Yes.

MS EASTMAN:  In that capacity you have oversight of the Faculty of Medicine's education programs?

PROFESSOR VELAN:  That's correct.

MS WRIGHT:  Thank you.

Dr Tracy, just starting with you, through your work with the Centre for Developmental Disability Health, you have been involved with a number of universities in Victoria and a number of degree programs.  Is that right?

DR TRACY:  Yes, that is correct, although most of our teaching happens at Monash University.  But we have been involved with the University of Melbourne and Deakin University.

MS WRIGHT:  The Centre was physically based at Monash University until 2015,  
that is the case?

DR TRACY:  That is right.  From 1991 when it was established, until 2015, it was within the Faculty of Medicine at Monash University.

MS WRIGHT:  Where is it currently based?

DR TRACY:  At Monash Health, which is the largest health service in Victoria.

MS WRIGHT:  One of the Centre's main goals and teaching methods is to bring the voice of people with disability into the teaching about intellectual disability, is that the case?

DR TRACY:  Yes, we think that   we know that people with disabilities are the experts on their own experience and on their own needs, and that bringing their voice into the learning environment for students is a really key part of challenging those assumptions and expectations and value judgments that can sometimes be part of unconscious bias, I guess.

MS WRIGHT:  One of the ways you do that has been by employing tutors at times to teach the content?

DR TRACY:  Yes.  The two main ways we have involved people with disability is through the employment of tutors with disabilities to work with our Monash medical students as part of their general practice rotation, where students get the opportunity to work on advanced communication skills with their tutor with a disability, and that is a very valued part of the curriculum by both the medical students and indeed by the tutors themselves.

MS WRIGHT:  And how is it that you have identified tutors for that task?

DR TRACY:  Over the years we have worked with a number of organisations and individuals, so there have been self advocacy organisations, there have been individuals who have expressed interest.  But for the last five years we have worked with a disability organisation, Yooralla, in Victoria, where they have been able to provide the tutors with a kind of support prior to the session and during the session, and debriefing opportunities after the session, and we have found that partnership to be very helpful.  And tutors, they invite tutors to be part of the program which happens --- well, pre COVID happened four times a year.  We very often have the same tutors asking to be part of it again, they really enjoyed the experience and valued the experience.

MS WRIGHT:  I take it that you would agree with the second of the propositions set out in the document that was provided before the hearing, that is to say, which proposes that education bodies seek to ensure that curricula are designed and developed in conjunction with people with cognitive disability and delivered using inclusive teaching practices?  Do you agree or have any further comments about that  
proposition?

DR TRACY:  Yes, I very strongly agree with that.  Although there are logistics reasons, realistic challenges for bringing people with disability into learning environments, and so one of the ways we have addressed that is to develop an inter professional teaching and learning package acknowledging and valuing the input of the multi disciplinary team that need to work with somebody with a disability, so we worked with nurses, dentists, physios, OTs and disability support professionals and many others, who   and particularly we worked with six people with disabilities and their support networks to develop stories that were around their life, and took students out of the context of a medical environment into their life but highlighted particular issues that were relevant to healthcare.

And we have found that audio visual method of introducing the voice of people with disability into the classroom environment has been a very helpful one.  It still gives the student the sense of meeting somebody but allows us to do that in quite small grabs of video relevant to the teaching content at the time.

MS WRIGHT:  Professor Velan, does the University of NSW use any such audio visual resources to bring the voice of people with disability into the medicine and surgery degrees?

PROFESSOR VELAN:  We have a limited amount of such materials which are used in the early part of our medicine degree, particularly around the scenario of a child and his family, and the child is living with Down syndrome.  But certainly more use could be made of such materials.

MS WRIGHT:  What about at the University of Tasmania?

PROFESSOR BULL:  It would be similar.  We would have limited material that we use in the symposium, and within case studies.  But I think the   to have an organised collection which we can all use would be extremely useful.

MS WRIGHT:  And is there scope in your view, Professor Bull, to have common or shared content across several health disciplines, not just across universities but across health disciplines within the same college at your university?

PROFESSOR BULL:  Yes, I think that is absolutely essential, it is a very inter professional   healthcare is inter professional by its nature, and so the more we can share and understand the nuance to particular professions, the better.

MS WRIGHT:  Just coming back to you, Dr Tracy, in your statement to the Royal Commission you have described the education and training in Australian universities about intellectual disability health as having a fragile basis, that is at paragraph 26.  Could I ask you to explain what you mean by that, Dr Tracy?

DR TRACY:  Yes, I certainly will, and I would also like to make the point of the  
importance of focussing our resources on adults with disability.  Traditionally, disability has been taught in paediatrics, and the case examples are often paediatric case examples, but people live most of their life as adults and it is adult medicine that we really need to influence and model for our next generation, and treating people as adults and how do you treat people as adults being cognisant of people's differing capacity and ability to communicate?  So it is really important that our teaching focuses on adults.

So my work in this area was   has been directed and in formed by my life experience.  I have a 35 year old son with intellectual disability and cerebral palsy who is not able to use speech to communicate, and he has had many health issues throughout his life.  When he was about 6, I looked for ways of combining my medical qualification with what I felt I had learnt already as a parent on that journey with him, so started working in the disability field at first with children with disabilities and their families and carers, and later, a couple of years later, I joined the adult Centre For Developmental Disability Health and that is where I have worked ever since.

Now, my personal experience has given me the passion and the drive and the energy to push for inclusion in the curriculum over the years, and because we were established within Monash University, and we had a very supportive Department of General Practice in which we were located, there were opportunities for me to contribute to the curriculum right from the beginning.

And when the medical degree underwent a major review in the late 1990s, I was then in the tent, if you like, and able to contribute and be part of that curriculum review, and suggest both disability specific content but also integrating cases of people with disability into endocrine medicine or orthopaedics or whatever the cases they were.  So it was incidental that a person had an intellectual disability, or cerebral palsy, where the main focus of that particular case might have been some particular medical issue.

So we had both the disability specific content and then weaving it into the general teaching.

In terms of the fragility, it's --- I guess, as I have got old and a little less energetic, no less passionate, no less passionate, but a little less energetic.

MS WRIGHT:  I get that.

DR TRACY:  It has been harder to push for ongoing change and renewal.  Now, we have had the support of Monash University, but we are geographically separate from   and distanced from the other two medical schools in Victoria, and just for logistical reasons and because of the lack of relationships, we have not been as successful all the way along the line in including curriculum content in their medical curricular.  And that has been a great shame for me.  I would like to get all the medical students to develop that basic knowledge and understanding, because we hear from the medical students in Year 4, so their second last year at Monash, that  
this is the first time they understand the cerebral palsy, this is the first time they understand intellectual disability, this is the first time they have thought about how those disabilities impact on communication, and what they as clinicians will be able to do to facilitate communication and make it easier and involve people directly in their healthcare.

So we know students need it, and we know students value it when they get it.  But it has   I have been a champion in Victoria for this area; there have been other champions in other States at various times, but it is too fragile because we get old and worn out, and we need to have that as a sustainable part of our health professional education, across all the health professions, but my focus has been medicine.

CHAIR:  Dr Tracy, I think you indicated that your organisation is now within Monash Health and not within the university.

DR TRACY:  Yes.

CHAIR:  How did that come about?

DR TRACY:  It was a change in the way   in the priorities of Monash University, moving from being a Victorian organisation perhaps to being an international university, and priorities shifted and changed, and it became more appropriate that we were located within a health service.  And that has had exciting opportunities too, and because of the long association with Monash University we have been able to keep a part of that community as well.

CHAIR:  Has the move in any way limited what you can do within the medical faculty at Monash?

DR TRACY:  Probably not really limited, but perhaps made it a little bit more difficult.  I used to be part of curriculum review meetings each year and could contribute some ideas to those.  That has not happened since we left the university.  So just for some of those reasons, it is very helpful to be in the tent, but it is also great to have access to the health professionals in a health service as well.  So there are benefits.

CHAIR:  I wonder if Professor Leech has a view?

PROFESSOR LEECH:  Thank you.  Yes, I think we have really benefitted from the expertise of Dr Tracy who has put in a very thoughtful, integrated, longitudinal approach, but I do agree with her that there is always room to enhance that and to increase the partnering with patients and families earlier in the course as well.  Like Professor Velan, we have a very early case in the Medicine course in Year 1 on Down syndrome in a child, but I think there are opportunities more to partner more there.

 
Dr Tracy has done really good work in the formative aspects of medical training at Monash, and I definitely agree there is room to strengthen those.  But I actually believe her positioning in the health system now could can be more powerful in terms of the impact that the organisation can have, and that is because knowledge and training are important but experience is having.  If she is able to work with health professionals   because our learners go from a campus based learning environment which is quite controlled, into a hospital based learning environment which is quite uncontrolled, I think that the ability to foster best practice learning in that environment is where the power to change can really be, and so certainly I think we do have a good relationship with Dr Tracy so she is always welcome inside the tent at any time.  I think she knows that.  She is a pretty busy lady, but she is always welcome inside the tent at any time, she knows that, and she still informs and works with us, but not --- I presume there are time constraint, too, but it is not the fact that she is not welcome.  She is welcome always.  But yeah, thank you.

DR TRACY:  May I just say something about the health service placement?

MS WRIGHT:  Certainly, Dr Tracy.

DR TRACY:  I absolutely agree with Professor Leech that the undergraduate education is just the beginning, and I think it is really important we get the foundations right, some basic attitudes, some basic skills, but doctors live most of their lives out in practice, not in medical school, and we need to include professional development along the way, education opportunity for trainees at different stages of their training, and we need to also   and you would have heard this from Professor Trollor --- a focus on specialist training in this area particularly between the ages of 18 and 65, because the paediatricians do a really good job prior to 18.  The geriatricians do a good job in holistic care after 65, but there is a gap from 18 to 65 where we do not have a specialist who can coordinate and understand and lead care, or medical healthcare or medical care in that area.  So it needs to happen on a number of levels.

The difficulty is getting people face to face, getting to people, once they leave medical school, and the huge benefit of getting to them at medical school is that we have the whole cohort captured, and that is a great opportunity to develop those basic skills, whereas using your lasso to get them in later in their training is you much less effective.

MS WRIGHT:  We will have a panel tomorrow looking at specialities, the medical colleges and sub specialities and speciality training.  But just picking up on what you talked about, both Professor Leech and Dr Tracy, Dr Tracy, you distinguished between a disability specific content and in that context you are talking about these core competencies or foundational knowledge to which you referred, and you distinguish that from case studies where a disability or cognitive disability is incidental to a particular scenario that might be put to students.  I just wanted to take that up with both Professors Leech and Velan.

 
I take it from your statement, Professor Leech, that the teaching at Monash in this area is integrated throughout the curriculum and not taught in distinct modules, is that right?

PROFESSOR LEECH:  That is right.

MS WRIGHT:  And it is largely taught through the case study model, using a person with a cognitive disability as the example patient, is that how a case study works?

PROFESSOR LEECH:  That is correct.

MS WRIGHT:  And through a range of subjects?

PROFESSOR LEECH:  That is correct.

MS WRIGHT:  Does that approach, do you think, provide sufficient focus for students to learn that type of foundational disability specific knowledge to which Dr Tracy is referring?

PROFESSOR LEECH:  I think it does provide a good foundational basis.  It does not mean that it cannot continue to be strengthened, and I think that one of the things that the educationalists here --- I know Professor Velan and Professor Bull would probably agree with me --- is that one of the problems with standalone content is that it tends to stick out like a sore thumb.  Students will often see it as almost an optional thing, a must do.  When you deliver content that is actually close to or proximal to the ability to experience something, you often drive deeper learning, which I think we have seen in Professor Bull's statement.  I think it also   Professor Bull   it tends to mitigate against the measure of tokenism so that students see the issue of intellectual disability as part of the whole of health and all the other health issues and co morbidities, so no matter what a person with intellectual disability is experiencing as they engage with healthcare at every stage of development, and I must amplify what Dr Tracy has said about adults because we both work in the health system.  I work in a health system and I 100 per cent concur that the health disparities the Commission is looking into are still very present, and particularly I see adults with disability, it is like they fall off a cliff.  When they are younger there is a speech therapist, a dedicated nurse, an occupational therapist, a physiotherapist and a full team, and they simply fall off a cliff usually when they reach adolescence, and they come into a health system that is hard to navigate.  So for us, we need to deliver the learning in such a way that it is across the journey, somebody with intellectual disability, our learners will see how it impacts, so if they are pregnant, if they   as they are becoming older, as they face other co morbidities --- health issues such as chronic disease, so we need to have a learning that is valid as well for the students, that they see the whole person.  So that is one reason for its integration, to support integration, but a second reason is that it means that if a student has just learnt something and then they get the opportunity to experience it in the clinical environment, it will drive home deep learning.  And also with education theory space repetition is what works so if you teach something once they sort of say, "Hey, I  
think I know that".  But you teach it again a little bit later, it just goes in a bit more, and you try one more time, it works really well.

If you want to go to the minimum, you try to go for the very beginning, formative, primacy and then very end, recency, just in time learning, but ideally most of the medical curricula try and space it across, so hopefully think that makes sense for the rationale of the more longitudinal approach.

MS WRIGHT:  Professor Velan, I will bring you in, you also speak in your statement about medical schools mostly taking this approach of integrating learning about disability with learning about holistic aspects of medical care and mainstream medical education, and you state that that foundational knowledge can be translated to the healthcare of any person.  So at the University of NSW the teaching is also done in this fashion, is that right?

PROFESSOR VELAN:  That is correct.  I fully concur with Professor Leech's opinions on this matter.

MS WRIGHT:  And what are some of the holistic aspects of medical care that are seen through the lens of a person with cognitive disability, can enhance students' learning outcomes generally?

PROFESSOR VELAN:  So we would like all our students to see all people who they care for as whole people, including their social, emotional and psychological health as well as their physical health, and also in the context of their society in the context of their local environment.  So with the example of intellectual disability, we would want our students to be fully aware of Article 25 of the Rights of People with Disabilities from the United Nations, but we would also want them to see them as people equal to every other person, and to provide them with holistic care.

MS WRIGHT:  Is there a risk, do you think, that that approach does not provide sufficient focus for students to learn about their future role in addressing the particular health inequities of people with cognitive and intellectual disabilities when there is not specific content on this subject?

PROFESSOR VELAN:  Yes.  I think we should not confuse a lack of a dedicated unit of teaching with a lack of specific content.  So there is specific content in our medicine program, and that of Monash and University of Tasmania, and, I would expect, all medicine programs on intellectual disability.  But it might not be in a dedicated unit of study.

But as Professor Leech said, that teaching is reinforced from the beginning of the program through experiences later in the program as well.  So the idea is that the iterative of these concepts are reinforced for the students so that when they graduate, they are competent to meet the needs of people living with disability as well as all other people that they encounter.

 
CHAIR:  Can I ask, please, how do you know whether this works?  Bearing in mind what the Royal Commission has heard in Public Hearing 4 and of course we have to be careful not to extrapolate too far from individual cases, but there does seem to be evidence that parts of the medical profession, in any event, are not very good at dealing with aspects of the treatment of people with disabilities.  I wonder what mechanisms there are for faculties, or indeed for the medical schools in general to determine whether the outcome that you are confident you are producing actually are working in practice.

PROFESSOR VELAN:  So I think that is a difficult question to answer, because medical schools are responsible for education up until graduation, and most of   have a person's growth as a medical practitioner will occur post graduation, so we prepare them as a generalist to be competent, as a recent graduate, but then they need to develop further over time.  So we can provide them with a basic grounding, but then further education is needed for them to develop specialist knowledge in dealing with people with intellectual disability and a variety of other conditions.

COMMISSIONER ATKINSON:  Professor Velan, obviously you assess your students, so do you assess them on their ability to communicate with people with disability, their capacity to not to do diagnostic overshadowing, their capacity not to have unconscious bias when dealing with people with disability?  Do you assess those things during the end of the medical course?

PROFESSOR VELAN:  We assess communication skills at all stages of the medical program.  Some of those assessments may relate to all of those issues that you have raised, but it would be safe to say there is no assessment that specifically focuses on those elements that you have raised.

COMMISSIONER ATKINSON:  It is true to say, isn't it, that students tend to concentrate on those matters that are assessed, so unless they are assessed, students might not regard them as particularly important?

PROFESSOR VELAN:  I agree with that statement.  There is nothing that drives learning more than an assessment.

CHAIR:  It was ever thus.

Can I ask whether any of the faculties represented today have a statement as to the competencies in the areas of intellectual disability or treatment of people with disability that students are expected to acquire by the end of the course?

PROFESSOR LEECH:  Should I go first?

CHAIR:  By all means.

PROFESSOR LEECH:  Thank you.  I think the package that Dr Tracy has developed for Monash, there….in the way of learning and assessment of communication skills  
by the people with intellectual disability who teach into the program that she has developed.  But I agree --- again I agree that could be strengthened.  I think in medical schools we can look at knowledge, we can look at skills and we can try to look at attitudes and try the look at behaviours.  How people behave in the controlled environment of the campus is one thing, and how they behave in the uncontrolled environment of the healthcare setting is another.  I think that we all agree   I feel that   I feel myself, as a health practitioner of many, many years, that there are times when I think I provide good care and there are other times where I think, because of the circumstance I'm in, I do not necessarily provide the best care that I could be providing because of the situation that I'm in, and not to make excuses, but I believe that it would be extremely useful for this to be assessed.

The question of   as Dr Tracy has alluded to, this is a longitudinal journey of learning and it is very much something that needs to be continuously reinforced and reassessed.  The idea of assessing it at the end of this very formative phrase --- I think medical school is like primary school, it has been said, and everything that happens afterwards is like high school and university and life --- so I think there would be a case to look at people's communication skills at exit.  But then more importantly it would be to look at how they behave as they move into the environment in healthcare, and are they seeing best practice examples of care.  Because my feeling is that nursing students, physio students, occupational therapy, all health students and medical student, most of them   I mean, there are a few bad apples in every profession as we know, but when people start out they are actually quite altruistic, they want to help, they want to do the right thing, they want to be good, they want to talk to people and understand and help.  What sometimes happens when they get into the healthcare system is that they do not see good practice, and so they start to model themselves on that, so you can vaccinate them and test them and look at their ability to respond, and that is a very important foundation, but I think we do need to concentrate on assessing behaviours in the workplace itself, where that is the real interface of patient care.

So yes, I think we could increase that assessment at exit, but I do not think we should do that at the expense of really trying to look at how we reinforce that when those student are out in practice, and I will let the experts speak now and back off.

DR TRACY:  May I say something?

MS WRIGHT:  Yes, Dr Tracy.

DR TRACY:  Thank you.  We absolutely agree that assessment drives learning, and we have   we used to   now again this has got lost in the last few years, but we used to regularly submit, they call it OSCEs or case examples for the medical student exams and well as multi choice questions, and students, just knowing that they might get a case on somebody with an intellectual disability, and there might be questions in their exam about a person with intellectual disability, makes them take this session seriously.  For many years I was a regular examiner as well both of those disability cases and others, and seeing me around with the examiners made them take us more  
seriously.  So I think we need to acknowledge that assessment does drive learning, and use that as a lever.

The other thing I wanted to say in terms of does it make a difference to students.  One of our questions in our evaluation is, "Do you think that your care of somebody with disability has changed in any way or will change in any way after this teaching session?" And students say things like, "Yes, I now understand how people can express health --- how physical and mental illness can be expressed by a change in behaviour.  I now understand how I have to modify my communication to suit my patient".

So very basic lessons that the students themselves are reporting that they have had a light bulb moment, they have understood something really basic for the first time in relation to people with intellectual disability, and although that is not assessing their post graduation behaviour, I totally accept that, it is to me an indication that we have helped them understand a basic concept that they will be able to take forward with them.

CHAIR:  It is not just a matter of learning a particular skill, what you have said is very important.  But it is also the recognition that there is something very important that they will need to develop as they practise through their professional lives.

One of the foundations of wisdom, I think, is knowing the limits of your own competence, but also knowing when you need to get some more instruction or to develop your skills throughout your professional career.  So it may not just be a matter of "I now know how to deal with someone with intellectual disability", but "When I'm in practice and encounter people with intellectual disability, if I feel that I have not perhaps addressed this particular patient in an optimal way, then I will get some more assistance in terms of continuing education" and so on.  That may be part of it, mightn't it?

DR TRACY:  Yes, absolutely.  Michelle was saying that they are altruistic when they graduate, and that is true.  We use audio visual medium like the 7.30 Report where, of the example that came out just after Julian Trollor's paper was published where there was the example of somebody who had behaviours that were diagnosed as a temper tantrum in emergency, with a young woman screaming, and on the floor, and then she died of meningitis some hours later.  The students are profoundly shocked at that, and we use that as a way of saying "We really need to understand people's behaviour, it is   behaviour is a symptom; like pain, we need to understand where it comes from.  It is not something to treat with antipsychotic medication or other sedatives".

COMMISSIONER ATKINSON:  You are not suggesting, Professor Leech, that it is either/or, students should have --- that once they graduate, then is the time obviously, you are not suggesting they do not need education at university as well as a foundation for when they leave?

 
PROFESSOR LEECH:  Yes, you are absolutely right.  What I'm suggesting is that we need both, we need all, absolutely.  So we need what we have.  I think at Monash we could do more patient partnering, actually, at different phases of the course.  And I also believe that we should continue to try to reinforce this across the journey of somebody.

One of the things is that people like Dr Tracy are in quite short supply, may I say, people with that level of expertise.  I could not agree more, and I know this is a subject of another hearing, but I really think that we need to develop a network of experts, you know, who are trained, particularly in adult disability, who can inform healthcare and education across the spectrum.

One of the things I have often felt, and I'm not sure if this is the right moment to bring this in, but I think in every area like teaching, law, medicine, any career, people start out with a lot of big ideas and they sometimes then become very hardened because of the culture that they go into.  I think it is a very good opportunity in this part of their education to try to vaccinate them against some of that hardening of the attitudes, so we must never lose that.  But I do think then more work needs to be done, because once they hit the culture often that hardening of attitudes increases.  I think you see this in many professions.  The problem with health is we are dealing with very vulnerable people, very vulnerable, and the problem with people with intellectual disability is that they are at the extreme end of that vulnerability.

We heard earlier that 1.8 per cent of the population is affected by intellectual disability.  That is a number that in health services we could work with.  I would really like to see the idea of adult land, you know, we had little teams in health services like a nurse, a special   a specialist trained nurse, a doctor maybe, but a physio, a social worker, little teams, that when a person with intellectual disability came into the health system, that they could be activated to help that patient and family navigate the system, and then my students, and Rosalind's students and Gary's students, could see that best practice playing out.  Because I think that would be so powerful for them to see that modelling going on in their futures.

As well as that, Rosalind and all the professors here will tell you that the team is so important.  The team can modify your behaviour.  If you are working a wonderful nurse, they can say, "Hey, don't you know this is the best way to talk to someone?" You can learn from the team.  So I think educating the whole team is key, rather than standalone in a medical course.

CHAIR:  I think we better give Ms Wright a chance to have a speaking role.

MS WRIGHT:  Thank you.

Could I bring you into the conversation, Professor Bull, sitting there patiently.  Do you have a view, like Dr Tracy, that universities are currently reliant to a large extent on individual academic staff or champions who advocate the inclusion of cognitive disability content?  Do you think that is an issue?
 

PROFESSOR BULL:  Yes, I do.  I agree absolutely that this is very fragile at the moment.  I think one of the best ways forward would be to really embed this in the leadership, governance and the strategies, the strategic intentions of universities and other health organisations to say, "This is an area of great importance, we will put our resources behind it".  Resourcing is a clear indicator that this is supported.

MS WRIGHT:  The University of Tasmania conducted its own internal review, did it not, in 2013 on its medical curriculum and on the healthcare of people with disability, whether that was properly represented within the medical curriculum?  Is that right?

PROFESSOR BULL:  That is right.

MS WRIGHT:  Was that prompted by the advent of the NDIS, do you know?

PROFESSOR BULL:  It may have been related to that.  I cannot say that for certain.  But the two people who drove that were advocates.

MS WRIGHT:  That was Dr Nick Cooling, an academic at the university, and he did recommend updates to the medicine curriculum.

PROFESSOR BULL:  Yes.

MS WRIGHT:  Were those recommendations adopted by the University of Tasmania?

PROFESSOR BULL:  Yes, they were, into the medical curriculum and also interestingly into the nursing curricula that is just coming forward now.  So there is quite a significant change in the level of commitment, I think, to ensuring people with intellectual disability are a focus --- are a greater focus.

MS WRIGHT:  Your courses in the College of Health and Medicine are undergoing transformation at the moment, is that the case?

PROFESSOR BULL:  Yes.

MS WRIGHT:  How might that review examine the content on cognitive disability?

PROFESSOR BULL:  So, as the others were talking, I was thinking around the way we look at curriculum and the way that we   that students journey through that curriculum.  So if we have a look at what are students doing right at the very beginning, they are learning about the healthcare system, they are learning about themselves within that healthcare system as a student and as a nascent healthcare professional.  They are learning about bits of the human body, when they work, when they don't work.  They are also trying to think about how they respond to things, and so I think that a review starts right at that end, to really understand the student  
journey of this and how best to bring along the learning that a student needs.  So having a complex conversation to assist a family to navigate the health system would not be a reasonable thing to introduce in the first year of a program or assess.  And so what we would be looking at for intellectual disability, working with people with intellectual disability, is a slow spiralling of knowledge.  So instead of saying "Here is what you have learned about congestive cardiac failure.  Here is a case study with a person who has intellectual disability and congestive cardiac failure, and you need to explain to that person and their family what blood tests they need, what ECG they need, what sort of treatment they need and what the trajectory of this is".

That is far more complex and draws on the student's knowledge of all those systems of communication and of themselves and that bias that may or may not be sitting there.  But that is a slow progress, and I think that is deep learning, which is why, (a), I don't think putting a single subject in is a good way to go, because that is   allows you to do a tick and flick and I do not think that is good, I also think we should be looking at capabilities rather than competencies, because capabilities assume that there will be continual growth and that is what we want to see in our health professions.

MS WRIGHT:  Is there any framework in assessing the adequacy and in reviewing curriculum?  Is there any framework available for the universities to determine what should be taught, whether the existing content is sufficient?  How do you benchmark the adequacy of existing content?

PROFESSOR BULL:  So we benchmark against each other but we also externally rate ---

MS WRIGHT:  When you say "Each other" ---

PROFESSOR BULL:  University, sorry, we have a look at each other's courses.  But we also are externally accredited, so we have external regulatory authorities that place standards on our courses and they will dictate, to some extent, greater and lesser extents depending on the regulatory body what must be in there, what must be tested, and at what time that actually occurs within the program.

MS WRIGHT:  Those accreditation standards will not go into the level of detail, for example, of what is said in propositions 3 and 4 in the propositions document about teaching unconscious bias, about diagnostic overshadowing, making adjustments to standard practices, specific communication skills relating to treating and caring for patient with cognitive disability.  So looking at other universities and collaborating is one method, but how do you determine overall that across the whole of a given degree, the content is what is required?  In the face of the very significant evidence about health inequities?

I think what I'm leading to is, do you see a need for a nationally consistent competency framework, which is one of the other propositions which has been put up for discussion?
 

PROFESSOR BULL:  To answer that second part of the question, yes, I think a national capability framework would be absolutely terrific.  Because that would allow what are nationally regulated professions to come out with the same level of capability, so we would know that people were able to operate well.

I think the   the missing element is around what you are discussing there, is the registration standards that nurses, doctors, physios, et cetera, et cetera, have to respond to as well and they are, they do specify.

The other areas that many of the evidence guides for accreditations will also provide, are the examples of what are expected in there.

So certainly the ability to communicate across a whole range of different people is critical to all health professions.

MS WRIGHT:  Professor Leech, is there any attempt made by your university to determine whether the content across the whole of the degree is adequate and against what sort of measure or benchmark is that done, if it is done at all?

PROFESSOR LEECH:  So --- is this in the terms of intellectual disability?

MS WRIGHT:  Yes, I think we are looking at cognitive intellectual disability     

PROFESSOR LEECH:  I agree with Professor Bull that we currently do not have a capability framework we use.  The most we have is the work that Dr Tracy has done, and that is in the penultimate year of the medical course, so it is quite an important time.  But I think that whilst we have, for example, now, frameworks to look at Indigenous health, knowledge and understanding and behaviour, I think that a national framework around   for this area would be very useful in guiding medical schools.

CHAIR:  That would have the advantage, wouldn't it, of leaving the medical schools or other schools or faculties autonomous in terms of the way they went about actually achieving the capabilities?  It is obviously not unlikely that a body such as a Royal Commission can stipulate the precise methods of teaching pedagogy and so forth, but a framework might provide something at which the schools or faculties could aim, then it is a matter for them as to how it is actually achieved?

PROFESSOR BULL:  Exactly.  That would be wonderful.

COMMISSIONER ATKINSON:  While there is a brief pause, could I just ask perhaps a very basic question?  What is the difference between a capability framework and a competency framework?

PROFESSOR BULL:  Are you okay if I answer this?  A competency framework is really a yes no answer, "Is the person competent in this area?"  There is a measure,  
and you can say, "No they are not competent" or "Yes, they are competent".  So it at its very worst level it is a tick and flick.

A capability framework is far more nuanced from that, so you are able to look at developing capabilities around that person and how they are able to shift, or use their knowledge in a broadening, widening range of contexts.  And that would be absolutely perfect for this, I think, for this sort of education, because it takes somebody who may have very little understanding, who almost certainly will have very little understanding, who may have a lot of unconscious bias and who may not be a splendid communicator and bring them along over a course of three to five years to a graduate health professional who has learnt a all of those things and has demonstrated developing capability all the way along.

That comes back to a question that was asked earlier around how do we know our students are demonstrating the what we need them to demonstrate?  We assess our students all of the way along.  So we are really assessing that developing capability.  And then are they achieving the standard for practice that their registering authority expects of a graduate.

PROFESSOR LEECH:  Thanks.

MS WRIGHT:  Professor Velan, you have said in your statement that it is important to recognise that it is not possible for universities to continually add content without overloading students.  I just wanted to take up with you the Aboriginal and Torres Strait Islander health curriculum framework which has been referred to.  What was the experience of the university when that came into place?  Was it initially difficult to find space, to your knowledge, in the curriculum for teaching Indigenous health?

PROFESSOR VELAN:  Yes, it was difficult, but it was difficult for a number of reasons.  Firstly, at our particular medical school we did not have an Indigenous leader to take carriage of this, which we now do.  But initially that was an issue.  And also the existing staff of the medical school needed to go on a journey of cultural competencies, and cultural safety as well.  So there was both logistical issues, cultural issues, but also the more prosaic issues of trying to figure out how to fit in additional material into an already crowded material into a curriculum.

MS WRIGHT:  That was obviously done, because it is now mandated by the accreditation standards.  What have been the benefits of incorporating the Indigenous health curriculum into the medicine degree at the university?

PROFESSOR VELAN:  So I would say we are still on a journey.  We are working on developing students' understanding of the history of Aboriginal Torres Strait Islander people and the relationship between that history and the current health issues.  And also providing our students with sufficient exposure to the health issues experienced by Aboriginal and Torres Strait Islander people.  So we are incorporating those capabilities into the curriculum together with assessment in alignment with the accrediting body.  But it is an ongoing journey.  I think that if a  
national capability framework was to be implemented for intellectual disability, then a similar journey would be required.  But I would say that it would need to start with the accrediting bodies changing their standards.

MS WRIGHT:  I think your have also said that advocacy would be needed from both the Australian Medical Council and the Medical Deans, Australia and New Zealand.  Is that right?

PROFESSOR VELAN:  Yes, that is correct.

MS WRIGHT:  Of course the AMC is the accrediting authority.  What is the role of the Deans?  What role do they play in supporting the forms to curriculum?

PROFESSOR VELAN:  The Medical Deans of Australia and New Zealand play a very useful role in all medical schools in creating awareness of changes in curricular, creating awareness of the resources, sharing resources between medical schools.  And I think in this particular area, the creation of a toolkit with shared resources would be beneficial for all medical schools.

MS WRIGHT:  Professor Leech, could I ask you what your university's experience has been of finding space for the Indigenous health curriculum framework, and if you are able to speak to any benefits that flowed from incorporating that content into the medical and nursing degrees, if you are able to speak to that?

PROFESSOR LEECH:  Sure, thank you.  We, like Professor Velan and UNSW and all like all Australian medical schools, I think, are still on a journey.  Our Monash motto is "Ancora Imparo", "I am still learning".  And that is something that applies to all of the incorporation of all these capability frameworks, that we need to be open to ongoing learning.

We have been very lucky to have excellent Indigenous leadership at Monash and excellent community engagement.  I think we have increased the number of medical students who are of Aboriginal and Torres Strait origin.  We have an integrated curriculum across the years.  Interestingly, recently the Gukwonderuk unit that guides this education framework for us and are responding to a national guideline, so this is a good model for us to look at, so a national guide line has been very useful.  Coupled with that, as Professor Velan, said the Medical Education Collaborative Committee of Medical Deans Australia and New Zealand have shared resources across universities, so it is a good model to look at there.  But an absolute key, I think, has been community engagement, so that would follow in the area of intellectual disability.

One of the things, too, is that if you are good at this, if you are good at understanding other, if you are good at --- if you are aware, culturally --- if you are self aware.  I mean self awareness, that training that you get, it is good for everything.  You are going to be a good doctor.  We do not know how to measure what a good doctor is.  One of the things is being aware of yourself as you carry yourself through the world.   
Being kind.  If you cannot be kind, having good manners at least.  Being able to know the limitations.  These are some of the things that I think this Indigenous health curriculum framework is teaching --- self reflection, self awareness, some of the same skill sets that will be critically important to help vulnerable people with intellectual disability in the system.  But people with intellectual disability have specific needs.  Should there be anything discrete --- and I would really welcome the UK findings.  The UK evaluation will be very instructive to us, if the introduction of a discrete unit or mandatory entity within a teaching program has proven to change outcomes for patients, we should listen to that.  But the way we are doing it with Indigenous health is very much an integration model.  But they recently have introduced a stand alone mandatory Learning on Racism.  And so is there a need for a small amount of something mandatory?  I think that is something that this Commission will continue to explore.  But I think you have heard from most of the educators here and others that you must not do that at the cost of the continuous integration model.

MS WRIGHT:  Can I ask, finally, what would you like to see in place?  I open that to all of you.  Perhaps starting with Professor Leech.  What would you like the see in place in five years, if it is mandated that curriculum be enhanced in the area of cognitive disability health?  Or if in your own assessment you decide that there is the room for improvement?

PROFESSOR LEECH:  I think I would like to see the enhancement of curricular is guided by a network of experts who have practical real world experience of what it is like for patients with disability, as well as patients and families with disability guiding the development of that framework.  And I would like to see a purposeful deliberative approach to this that takes into account the whole education journey.  I think we would be very, very keen in medical schools to be part of that process, wherever the strengthening is required.  We would be very keen to --- we would welcome that.  I would really welcome such a national framework myself.

MS WRIGHT:  Professor Bull, what would you like to see in place?

PROFESSOR BULL:  I would like to see a national commitment, and that extending across the health professions and the unregulated health workforce, because they are a really important component of all of this.  I would you like to that national commitment linked to shared resources, into professionally shared resources.  And I would also like to see a much less fragile leadership in this space.  So to know that our leading health professions were carrying it forward and there was an expectation.  So it would being prospectoral, I suppose, in terms of accrediting bodies, the higher education sector, and so on.

MS WRIGHT:  Professor Velan?

PROFESSOR VELAN:  Thank you.  I think it is key to have a collaborative approach across at a national level to develop resources that are available for healthcare professional degrees across Australia.  And the network that Michelle  
referred to of experts in this area would be key to the establishment of such resources, but also appropriate funding for the development of e learning resources that could be shared nationally.

As well as that, it would be helpful if, in all regions where healthcare profession degrees are taught that there are relationships built with advocacy groups and intellectual disability services to enable students to experience first hand the care of people with intellectual disability.

MS WRIGHT:  Dr Tracy, what would you like to see in place in five years?

DR TRACY:  I think the model of Aboriginal and Torres Strait Islander framework is a really helpful one.  We want all Indigenous Australians to receive good healthcare, and we want all Australians with intellectual disability to receive good healthcare, so we want a national approach.  It is still a relatively early development field, there are lots of people with lived experience who are wanting to contribute to this process, so certainly a framework that and leadership from experts with an advisory group of people with lived experience, and leadership from health professionals who often have lived experience.  There is a lot of cross over there, intellectual disability is common, many health professionals have somebody in their family with an intellectual disability, so a lot of people are wanting to contribute to the field.

I think that the competency framework developed by Professor Trollor and his team in relation to mental health is a really good model on which we could base a capability framework for health professionals that we are discussing.  Now, he has done a really excellent job, and I like the way he has laid it out in terms of the first part being working with somebody with a disability, so you are addressing attitudes, you are addressing communication, you are addressing legal issues of capacity and consent, and the sharing of health information.  A whole lot of things come under that.

Then there is the clinical competencies, and then there is the area of service improvement and continuous improvement and development, and I think that framework is a really nice one that he has laid out there, and we could certainly use that as a model.

And I would also   there need to be a workforce here developed who are teaching this.  One of the issues about having too much of a curriculum in case based examples, taught by people who are not familiar with working with people with intellectual disability, is it can be issues of the language used, the values imparted.  It is still an area that a lot of people have not thought a lot about if they have not come in contact with the it themselves personally, and so we do need to have appropriate modelling of attitudes and language, as well as competency in the actual clinical skills and knowledge.

MS WRIGHT:  So a capabilities framework could contribute to that in terms of the  
training of the teachers?

DR TRACY:  Yes, indeed.  And on a national level.

MS WRIGHT:  Thank you.  No further questions.

CHAIR:  I will ask whether the Commissioners present today have any further questions.  Commissioner Atkinson?

COMMISSIONER ATKINSON:  No, thank you.

CHAIR:  Commissioner Bennett?

COMMISSIONER BENNETT:  No, thank you.

CHAIR:  I would like to thank you, Professor Tracy, Professor Velan and Professor Bull for your contributions.  You have stirred up things past.  I remember, some decades ago, curriculum review committees and all of the work they did and the endless discussions.  I hope that our discussions over the next couple of days will produce more direct outcomes than some of the committee meetings that I remember.  But thank you very much indeed for coming and giving evidence.

I was just wondering whether, Professor Leech, when you mentioned the characteristics that you were trying to engender in the medical graduates of self awareness, kindness, compassion, if you were going to suggest that if someone lacked any of those characteristics they should study law.

PROFESSOR LEECH:  I would never say that in this context.

CHAIR:  Thank you very much.

THE WITNESSES WITHDREW

MS WRIGHT:  Commissioners, the next panel, if it is convenient to the Royal Commission, will be at 1 o'clock.

CHAIR:  At 1 o'clock?

MS WRIGHT:  Yes.

CHAIR:  Oh.  We have a little break.  Very good.  Okay.  We will adjourn until 1.00 pm.  Thank you.

ADJOURNED    [11.48 AM]
 

RESUMED    [1.00 PM]

CHAIR:  Yes, Ms Wright.

MS WRIGHT:  Thank you, Chair.

Commissioners, the next panel will consist of four witnesses from the field of nursing education and training and standards.

Associate Professor Nathan Wilson from the Professional Association of Nurses in Developmental Disability Australia, or PANDDA.

Professor Chris Brebner of Flinders University Nursing School.  Perhaps if Professor Brebner could indicate by waving your hand.  Thank you.

Ms Liza Edwards, Policy Advisor of the Council of Deans and Nursing and Midwifery.

And Dr Margaret Gatling, who is the Director, Accreditation Services, of the Australian Nursing and Midwifery Accreditation Council or ANMAC.

ASSOCIATE PROFESSOR NATHAN JOHN WILSON

PROFESSOR CHRIS BREBNER

MS LIZA EDWARDS

DR MARGARET GATLING

CHAIR:  Thank you, Professor Wilson, Professor Brebner, Ms Edwards and Dr Gatling, for coming to the Royal Commission to give evidence.  I understand you have each been affirmed or taken the oath as the case may be, so I will ask Ms Wright to ask you some questions now.

Thank you.

MS WRIGHT:  I will just provide a short opening.

Commissioners, each one of the witnesses has provided statements which are in  
Tender Bundle A.  This panel has a nursing theme, and our focus is on Propositions 1, 6 and 8, broadly.

Commissioners, at Public Hearing 4 Professor Julian Trollor gave evidence that training for health professionals should be based on an overarching national competency framework.  Support for a national competency framework was also expressed at the Second Roundtable on the Health of People With Intellectual Disability hosted by the Commonwealth Department of Health.  It was noted that the intellectual disability content needs to be integrated in competency frameworks and accreditation standards similar to competencies on providing care for Indigenous, Culturally and Linguistically Diverse communities.

A competency framework defines the knowledge, skills and attributes that are the outcome of a learning journey.  If implemented, a competency framework in the area of cognitive disability health would contain guidelines to assist universities and other higher education providers to develop and integrate cognitive disability health content in their core education.

There are a number of models of competency frameworks in existence in Australia.  One example is the Intellectual Disability Mental Health Core Competency Framework developed by the Department of Developmental Disability Neuropsychiatry at the University of NSW.  That is found at Tab 45 of Tender Bundle B.  It is a manual for mental health professionals in intellectual disability healthcare.  That framework may be more detailed than what is needed, but it appears to be a useful tool as we heard in the last panel, for the development of core competencies or capabilities in intellectual disability healthcare.

Another example is the Aboriginal and Torres Strait Islander Health Curriculum Framework, developed in response to a report in 2011 by Health Workforce Australia on the Aboriginal and Aboriginal and Torres Strait Islander health workforce.  That framework states the pivotal role higher education providers play in ensuring graduates have the capacity to work effectively and respectfully in First Nations health contexts.

It identifies the capabilities graduates will develop after doing studies in a tertiary setting where the framework is implemented.  It sets out learning outcomes, for example, around communication in a culturally appropriate manner with Aboriginal and Torres Strait Islander peoples.  A significant feature of that framework is that it was developed not only to assist universities to develop their course content, but also to in form revisions to accreditation standards being the standards the education providers must meet.  It offers guidelines for revising standards across the health system.

Its stated intent is not to be prescriptive, but rather to provide a road map by which education providers might be assisted when implementing changes to their degrees and courses.  In terms of the capabilities or competencies health professionals require when caring for people with cognitive disability and intellectual disability, there are  
some topics that have come up repeatedly in the evidence received by the Royal Commission to date and in academic literature: communication skills, attitudes and values, adjustments to standard practices to name just a few.

The Council of Deans of Nursing and Midwifery have said in their statement to the Royal Commission that there should be a level of agreement among stakeholders regarding a clear set of learning outcomes that would best support a person centred experience for vulnerable people that could be shared across undergraduate courses for health professionals.  The Council of Deans appear to contemplate mandated content.

Associate Professor Nathan Wilson has set out PANDDA's position, that there should be a national approach to mandatory education and training in intellectual and developmental disability, specific content for all health care professionals to build capability and capacity in IDD care.  Education and training should be included in both undergraduate and post graduate education courses of all disciplines and there should also be ongoing training through staff education and continuing professional development programs to address current gaps.

Similarly, Professor Brebner of Flinders University College of Nursing and Health Science states that a taskforce to develop a national framework for development and delivery of this important learning could facilitate the process in an appropriate and sustainable manner.

Professor Brebner also suggests that curriculum enhancement would be amplified if mandated in professional practice and accreditation standards for the nursing profession.

This panel will therefore begin to explore whether there is a need to revise accreditation standards and practice standards so as to mandate content in relevant degrees and diplomas.  I note that evidence from Virginia Howie, who we will hear from tomorrow, is also relevant to this topic, but first, Commissioners, we are going to hear from Corey Burke, who has been contributing to a nurse capacity building project led by Professor Andrew Cashin and Associate Professor Wilson, and that evidence will be provided by way of a pre recorded tape which we will play now.

CHAIR:  Thank you.

[VIDEO RECORDING PLAYED]

MS WRIGHT:  Hi Corey.  Is your name Corey Burke?

MR BURKE:  Yes it is.

MS WRIGHT:  Have you made a statement to the Royal Commission dated 7  
December this year?

MR BURKE:  Yes, I have.

MS WRIGHT:  Corey, would you be happy to read out your statement for us?

MR BURKE:  Yes, I might need some help by my mum though because I'm not a very good reader.

MS WRIGHT:  That is quite okay, and if you need to stop at any time, just tell us.  You can start now if you like, Corey.

MR BURKE:  All right.

I play guitar and sing.  I am in a band called the Outsiders, I play basketball and do athletics at the Special Olympics.  I represented Queensland in basketball at the Special Olympics National Games in Adelaide in 2018.  I like computers and I create replicas of theme parks like Movie World.

I am working on a project about training nurses to have better understanding of people with special needs, and that people with special needs need a little bit more extra care.  I am a part of a group people who help develop training.  We get together and talk about our experiences with nurses, and talk about nurses --- what nurses should know.  I am a also helping them with scripts for training videos for nurses that other people with a disability will act in.

When I go into hospital for an operation, I have trouble going under the anaesthesia.  My adrenaline goes up and I tend fight the anaesthesia.  One time I went into hospital for an operation, the anaesthetic did not work; I was conscious the entire time.

I have a mentor who helps me when I go to hospital.  When I went into hospital for the operation, the anaesthetist said that my mentor had to leave the room.  I was left alone with the doctors and nurses.

They gave me anaesthetic but I didn't go under.  I was still conscious and I tried to tell them but they did the operation anyway.  It wasn't painful, but it was very uncomfortable.

I think that this wouldn't have happened if my mentor was in the room with me.  My mentor would help to keep me calm and stopped my adrenaline from going up.

I think people should have a better understanding with people with a disability or special needs.  They should know that people with special needs need a little extra care, especially if they get anxiety and nervous, or act out.  People should know that things like having a safety blanket for someone or   can help if they are anxious or nervous.  I have a tool box that I keep sensory items in to bring my stressful situations down and it makes me less anxious.  I have a support dog too.  People  
should know about these things, so --- and let the people use them, especially in hospitals.

People should know that if a person is having a meltdown, it may not be a part of their disability, and it is not because they are a bad person.  People should know that helping a person having a meltdown by just sitting with them and saying "Everything is going to be okay" and understanding their emotions.

People don't know that I have a disability.  My disability is not visible so people do not really know until they meet me.  Sometimes nurses do not know I have a disability until they talk to me and ask me if I understood what they said, and I say "Not really", or I just nod.  It might be on   it might be on my medical records, but I don't see them and I don't know.  There should be something in the medical records to show that someone with a disability, that there could be a colour on their file so that when the nurses and doctors look at the colour they know they are dealing with someone with a disability, who has epilepsy or autism disorder or an intellectual disability.  If you know   if they have different colours for those things you could categorise them.  Nurses and doctors would know that someone has a disability even if they are busy and don't have time to read the file.

I think people should have something on their file that tells the doctors and nurses and parents needed to be present when they're talking to them.  Sometimes people sit in a hospital, and doctors and nurses say things when they don't really understand.  It could also be overwhelming especially when explaining a procedure or something that they can --- can be a bit dramatic.  If someone does not understand what doctors and nurses are saying, there should be --- parents have to find out from the doctor, trying to decipher it.  I think that there should be someone that parents   somewhere where parents can get information from where the technology   we have got technology now, so maybe there could be an app that could send updates from parents to let them now what is going on.

Everyone with a disability is different and they all have different needs.  Sometimes people need to look outside the box.  My doctor told me that he has a patient with a disability who refuses to come and see the doctor because they were nervous.  My doctor brought the needle and everything he needed out to the patient so it was not so confronting for him.  I think more doctors need to do   be like this.

I have a lot more knowledge to share.  This is just some of it.

MS WRIGHT:  Thank you, Corey.

MR BURKE:  No problems.

MS WRIGHT:  Corey, you said you were working on a project about training nurses.

MR BURKE:  Yes.
 

MS WRIGHT:  And you have a lot more knowledge to share?

MR BURKE:  Yes.

MS WRIGHT:  Are you sharing your knowledge in that project about training nurses?

MR BURKE:  Yes.

MS WRIGHT:  And you hope that nurses can have a better understanding of people with disability, is that right?

MR BURKE:  Yes, that is right.

MS WRIGHT:  Thank you very much for your time today, Corey, and for reading your statement out for the Royal Commission.

MR BURKE:  No problems.

[VIDEO RECORDING ENDED]

EXAMINATION IN CHIEF BY MS WRIGHT

MS WRIGHT:  Professor Wilson, is your full name Nathan Wilson?

CHAIR:  I don't think we can hear you, Professor Wilson, you may have to turn on your sound.

A/PROFESSOR WILSON:  Okay, yes, that is correct, yes.

MS WRIGHT:  You are the President of the Professional Association of Nurses in Developmental Disability Australia?

A/PROFESSOR WILSON:  I am indeed.

MS WRIGHT:  You are an Associate Professor in the School of Nursing and Midwifery at the Western Sydney University?

A/PROFESSOR WILSON:  Yes.

MS WRIGHT:  And you are also an Honorary Senior Lecturer at the Centre for Disability Research and Policy in the Faculty of Health Sciences at the University of Sydney, is that right?
 

A/PROFESSOR WILSON:  That is correct, although it is no longer called the Faculty of Health Sciences, yes.

MS WRIGHT:  You have been a registered nurse since 1992, and have particular expertise in nursing practice for people with intellectual disability?

A/PROFESSOR WILSON:  That is correct, yes.

MS WRIGHT:  Professor Brebner, is your full name Chris Brebner?

PROFESSOR BREBNER:  It's Christine Brebner.

MS WRIGHT:  Thank you, and you are the Dean (Education) of the College of Nursing and Health Sciences at Flinders University?

PROFESSOR BREBNER:  Correct.

MS WRIGHT:  You originally trained as a speech pathologist, is that right?

PROFESSOR BREBNER:  Correct.

MS WRIGHT:  And you have worked in a range of paediatric settings in Australia and overseas?

PROFESSOR BREBNER:  Correct.

MS WRIGHT:  Your research interest includes early communication development particularly with children with Culturally and Linguistic Diverse backgrounds?

PROFESSOR BREBNER:  Yes.

MS WRIGHT:  Liza Edwards, is your full name Liza Edwards?

MS EDWARDS:  Yes, that is my full name.

MS WRIGHT:  You are a policy advisor at the Council of Deans of Nursing and Midwifery?

MS EDWARDS:  That's correct, I'm also a registered nurse and have been since 1993.

MS WRIGHT:  The Council of Deans represents 42 schools of nursing in Australia and New Zealand?

MS EDWARDS:  Correct.

 
MS WRIGHT:  Dr Gatling, is your full name Margaret Gatling?

DR GATLING:  Yes.

MS WRIGHT:  You are the Director of Accreditation Services of the Australian Nursing and Midwifery Accreditation Council?

DR GATLING:  Yes, I am.

MS WRIGHT:  You have worked in nursing regulation and accreditation for several years?

DR GATLING:  Yes.

MS WRIGHT:  You trained as a registered nurse and have a doctorate which looked at societal attitudes to the care of the elderly, is that right?

DR GATLING:  Yes.

MS WRIGHT:  Associate Professor Wilson, I might start with you.  You have said in your statement to the Royal Commission that there is currently little content on intellectual and developmental disability in nursing curricula in Australia.  And you refer to the audit conducted by Professor Trollor into intellectual disability health content in nursing schools in 2014 that found that 52 per cent of 31 nursing schools examined offered no intellectual disability content.  And you have also noted the finding that where taught it was for an average of three and a half hours over the entire degree.

A/PROFESSOR WILSON:  Yes.

MS WRIGHT:  I will come back to talking about accreditation standards which you have mentioned in this context in a moment, but I just want to draw on your personal experience in teaching in this area.  You have referred in your statement to a course that you offered, and I think you developed it, at Western Sydney University, is that right?

A/PROFESSOR WILSON:  Yes.

MS WRIGHT:  That was into chronic illness and disability?

A/PROFESSOR WILSON:  Yes, so the unit was about chronic illness and disability with a focus on three of the national health priority areas, which was neurological, respiratory and endocrine disorders.

MS WRIGHT:  You incorporated content and case studies in that unit relating to intellectual and developmental disability, is that right?

 
A/PROFESSOR WILSON:  That is correct, yes.

MS WRIGHT:  And you thought that course until about 2017 when your responsibilities then changed.

A/PROFESSOR WILSON:  Yes, that is right.

MS WRIGHT:  Since that time you've found that the course content pertaining to intellectual and developmental disability has eroded from that particular subject?

A/PROFESSOR WILSON:  Yes, it is a gradual erosion over time for a couple of reasons, one being that there is an expectation that unit coordinators will revise roughly one third of the content of the curriculum each year to ensure it is current.  And the other thing that obviously happens is that when you get different academics with different expertise, naturally they will inject their own expertise in that to unit of study.  Just like I did when I created the unit, I injected intellectual disability into every part of it course, because I could.  And that was my expertise and so I did.

MS WRIGHT:  And you say that is actually a common story, where without a local academic or champion with an interest in the area, content in this area can be watered down and eroded quickly?

A/PROFESSOR WILSON:  That is correct, and that is also echoed in that paper you referred to by Professor Trollor and your colleague, that where there was content there was often a local champion who made sure that that content was embedded into the curriculum, yes.

MS WRIGHT:  Just further by way of some background, you speak a little in your statement about the historical reasons for a lack of training in intellectual and developmental disability in nursing schools.  I wonder if you could explain that briefly, and I'm referring to the part of your statement where you talk about the move from   of nursing education to higher education?

CHAIR:  Which paragraph?

MS WRIGHT:  Paragraph 21, 22.

A/PROFESSOR WILSON:  When nursing education moved into the higher education sector, there was certainly --- my direct experience --- that there were units of study on a range of population groups, such as paediatrics, aged care, mental health, intellectual disability and so on.  And that then gradually from around the mid 1990s onwards that was gradually eroded over time, for a whole range of reasons such as changes in the way the ANMAC standards were structured and so on, yes.

MS WRIGHT:  You have said there was an expectation it would be taught in undergraduate curricula, but that has not been borne out by what has occurred?
 

A/PROFESSOR WILSON:  Yes, and this goes back before my time, but my colleagues at PANDDA who are a little older than me refer to when the curriculum left the colleges of nursing that were based in clinical settings, that there was a reassurance and a guarantee that that would then carry on, and it at least did initially but was just gradually eroded over time.

MS WRIGHT:  Professor Brebner, Flinders University offers a Bachelor of Nursing and Bachelor of Nursing graduate entry degrees?  Is that right?

PROFESSOR BREBNER:  Yes.

MS WRIGHT:  You explain in your statement that the curricula focuses on patient-centred care and encourages students to contextualise their learnings about care for people from diverse backgrounds?

PROFESSOR BREBNER:  That is correct, yes.

MS WRIGHT:  And that Flinders in fact has a strategic focus in fact in the area of vulnerable populations and equity?  Is that right?

PROFESSOR BREBNER:  Yes, that is correct.

MS WRIGHT:  And you have said that   I think you fairly acknowledged at the commencement of your statement that the needs of people with cognitive disabilities do not currently have to be directly addressed in university curriculum?

PROFESSOR BREBNER:  That is correct.

MS WRIGHT:  Are you referring there to the Accreditation Standards not requiring it?

PROFESSOR BREBNER:  It is not explicitly stated in the Accreditation Standards that cognitive disability needs to be addressed as a specific area, but that the needs of vulnerable people in the provision of nursing care do need to be attended to.  So the curriculum we deliver tends to be more integrated encouraging students to consider the person as an individual and their critical thinking and reasoning about how they would support that individual, but not so much of a focus on content specifically around cognitive disability, for example.

MS WRIGHT:  The way it is integrated, is it by case studies and clinical simulations which you have referred to in your statement over the course of the degree?

PROFESSOR BREBNER:  We do that as well as placement or work integrated learning.  I would like to note that simulations for people with a cognitive disability are very difficult to do in a respectful manner, so that is not something that we have put a lot of content in around, because that would be something we are looking to  
co design with people with lived experience with disability and their carers, to be able to do that in an authentic and respectful manner.  But about 20 per cent of the population live with disability, so there is a lot of experience that our students gain out in their work integrated learning, their placement experiences, where they come into contact with people living with disability, and so they are encouraged to think about those individuals and reflect on their practice and that is integrated into the curriculum throughout so they are constantly reflecting on the needs of the people they are caring for.

MS WRIGHT:  Are those clinical placements ever in placements where   that are dedicated with patients with cognitive disability, that is, is it a planned exposure, or is it more of a chance or serendipitous thing depending on where the student is placed?

PROFESSOR BREBNER:  It is difficult to make it a planned experience for the volume of nursing students we have, and it is not possible to have a dedicated placement specifically for a cognitive disability, but instead these people who live with cognitive disability will present across all aspects of healthcare.

MS WRIGHT:  Does that mean that the majority of the formal education in relation to cognitive disability health is around the case study model?

PROFESSOR BREBNER:  At the moment I would say yes, in our curriculum.

MS WRIGHT:  Do you think that is sufficient for teaching specific issues to do with cognitive disability, and I'm referring to some of the topics dealt within the propositions document that you would have seen circulated, around things such as communication skills with this population, unconscious bias, adjustments to standard practices and the like?

PROFESSOR BREBNER:  It is my belief that we can always strengthen and further develop the curriculum that we deliver, and at the moment a framework would really support the delivery of curriculum in that way.  We do not have a human rights basis for our curriculum in nursing, but what we have been starting to do as a college with a large number of different health professionals, we have been bringing together inter professional groups to look at how we can incorporate all of those considerations.  So for example, our speech pathology team have expertise around the theories underpinning disability practice.

One of the other key things we are doing is we have a panel of scholars now, people with lived experience of disability or people living with disability who are employed to come in, and they have the knowledge expertise so they are working with our academics around co design of curriculum and how that might be delivered in an appropriate way.

A framework that is co designed with people with disability would really support that work to continue and to grow and strengthen.
 

MS WRIGHT:  You have referred in your statement to how the curricula is determined, and you have said there are four pillars of teaching and learning content.  That is at page 3, paragraph 2 of your statement.  One of those four pillars you have referred to as the Aboriginal and Torres Strait Islander health curriculum framework.  Is that the type of framework to which you have just referred where you have said a framework would greatly assist in the area of cognitive disability health?

PROFESSOR BREBNER:  Yes.  A developmental framework like that, co designed with people living with disability and adequately resourced, to have a really robust well designed framework would indeed support the curricula and yes, it would be very similar do the way in which the Aboriginal and Torres Strait Islander curriculum framework has been developed.

MS WRIGHT:  How do you take a document like that and translate it to actual teaching design and delivery?

PROFESSOR BREBNER:  How long have we got.  Really, we take those documents, we look at the principles and the core learnings, and often we will design a unit or a topic to introduce those theories and then we will integrate the content throughout the remainder of the curriculum.  So students, for example, with the Aboriginal and Torres Strait Islander content, will have a topic where they learn about theories, the histories, the perspectives, they have Malpa Aboriginal guides in that topic, and the content around working in a respectful way with Aboriginal and Torres Strait Islander peoples is integrated across all components of curriculum, across the remainder of the degree.  So we would envisage a very similar process if we had a framework for cognitive disability.

MS WRIGHT:  One of the other four pillars you refer to are the National Safety and Quality Health Standards for Acute Care Services.  They deal with clinical standards, is that right?  That is a nod?  Thank you.

PROFESSOR BREBNER:  Yes.

MS WRIGHT:  And they inform the content of the curricula development, curriculum development at the university?

PROFESSOR BREBNER:  Yes, we take all of the different priorities, national priorities, all of the different care standards, everything together to look at how best to design a curriculum to be delivered in three years, which will enable our graduates to graduate as registered nurses who are safe to practise.

MS WRIGHT:  You have a view about whether those National Safety and Quality Health Standards adequately address the needs of patients with cognitive disability?

PROFESSOR BREBNER:  I would have to defer to my nursing colleagues on that one, because I do not believe I have specific enough knowledge about the level of  
detail in those standards.

MS WRIGHT:  Sure.  Now, you have said that the work in this area could be amplified, if mandated, in professional practice and accreditation standards.  Is that right?

PROFESSOR BREBNER:  That is correct.  What we have seen nationally is when professional bodies embed requirements into accreditation standards and professional standards, that is directly then transferred into curriculum and teaching and it is   becomes a requirement and it is embedded.

MS WRIGHT:  Ms Edwards, I might bring you in here.  You have highlighted in your statement that individual members, individual nursing schools, are responsible for their own curriculum content?  That is the position?

MS EDWARDS:  Yes.

MS WRIGHT:  You have referred to   you have also referred to Professor Trollor's work and you have said a number of courses do include such content at the moment.  Is that right?

MS EDWARDS:  Yes, that is true.  I believe that study was done and included approximately half of the current nursing schools at the time it was conducted, and half of those nursing schools that responded said they did not include content with regard to intellectual disability.

MS WRIGHT:  Do you agree that is a poor statistic?

MS EDWARDS:  Yes.  I think at the time.  I think it is difficult to interpret because the responses were of only half the current nursing schools that delivered courses so I think it is difficult to say that if it was a response from the entire nursing school I would agree that that was a poor statistic, definitely.

MS WRIGHT:  31 is a fair number, do you agree?  Out of 31 schools, only 50 per cent or less are offering cognitive disability content, that is   that could be concerning?

MS EDWARDS:  I would agree that is concerning if 31 was the entire number of schools delivering content at that time, but I believe that was only half of those that were delivering content, so I think it needs to be taken in context.  Right.

COMMISSIONER ATKINSON:  Do you have any reason to think that those who were delivering good content, or content, did not respond to the survey?

MS EDWARDS:  No, I don't.  All I can say is that it was approximately half.  It was documented in that article that it was half, Commissioner, of those delivering content.
 

CHAIR:  Do you mean that the response rate was half?  That is half of the institutions contacted responded?

MS EDWARDS:  I believe it was half of the number of institutions delivering nursing and/or midwifery degrees at that time.

CHAIR:  Responded to whatever questions were asked?

MS EDWARDS:  Yes, Commissioner.

CHAIR:  But of those that did respond, half did not offer instruction in the care of people with disability?

MS EDWARDS:  That is correct.

CHAIR:  Right, so your query is whether the half that did respond is representative of the whole?

MS EDWARDS:  Yes, that is correct.

MS WRIGHT:  You have said that there is currently no mandatory minimum requirements in the ANMAC accreditation standards regarding cognitive disability.  That is right?

MS EDWARDS:  Yes, that is correct.

MS WRIGHT:  And if learning is to be mandated, it should extend to incorporate learning objectives and outcomes for registered nurse students across all vulnerable people?  That is the suggestion that the Council of Deans makes.  Is that right?

MS EDWARDS:  Yes, it is, yes.

MS WRIGHT:  Is that too broad a concept to address training   to address specific health inequities that have been identified for this population?  Do you think?

MS EDWARDS:  I think the work to be done is to address the inequities that vulnerable populations experience.  I think many experience difficulties accessing care and accessing high quality care, and in communication, and I think there is a piece of work to be done that actually looks at vulnerable populations across the board to identify commonalities that could be addressed for populations that are generally represented right throughout our population.

MS WRIGHT:  How does one identify vulnerable populations?  There would be many.

MS EDWARDS:  There are many.  There are absolutely many, and that is part of the  
work to be done.  These are people experiencing homelessness, diversity, culturally diverse populations.  There are many, many issues that are experienced by different populations with regard to access high quality healthcare, with regard to communication and a whole raft of different issues with regard to experiencing the health care that they need and the issues they have in accessing that healthcare.  And I think with relation to nursing and delivering the care that populations require, I think it is more than just looking at   I guess it is the issues that all the vulnerable populations experience.  And I think that for nursing is probably something that is difficult to fit into that three year degree in relation to one specific area, but the Council of Deans believes there is further work to do be done that could actually broaden out and include a greater number of vulnerable groups in relation to nursing education.

MS WRIGHT:  Has the Council of Deans had regard to, for example, Professor Trollor's work on the significant health inequities suffered by people with intellectual disability?

MS EDWARDS:  I don't believe so.  With regard to our contribution to the Commission, that they have, no.  We have been   sorry   in the roundtables at a late stage, so I certainly attended the roundtable in November, the second roundtable and was able to hear Professor Trollor's presentation to that roundtable.

MS WRIGHT:  The suggestion about incorporating learning objectives across all vulnerable people, could I reverse that and suggest that there has been some evidence this morning that people or patients in this group can be used as   that is, people with cognitive disability or intellectual disability can be used as an exemplar of healthcare in people with complex health needs to enhance training that can be applied to other vulnerable groups?  In other words, if you teach in this area specific to cognitive disability, you will improve students awareness and understanding of issues that they can then generally apply to other populations?

MS EDWARDS:  Yeah, I would agree with that.  I would agree.  I would also agree with that, with a caveat that it was looked at in a view of a number of other populations that may have homelessness, et cetera, that may have other issues, that may or may not be included in that.  But I agree, yes.

MS WRIGHT:  Dr Gatling, on accreditation standards, are you able to explain for the Commission ---

COMMISSIONER ATKINSON:  Before you leave, Ms Edwards, can I ask a question.

MS WRIGHT:  Yes.

COMMISSIONER ATKINSON:  Ms Edwards, you say in paragraph seven of your statement, or at least in question seven you talk about your participation in the second roundtable, but you referred to in your evidence just before.  Then it says  
there was going to be a smaller group discussion on university medical and nursing curricula tentatively scheduled for 19 November 2020.  Did that happen?

MS EDWARDS:  Yes, it did, Commissioner, and the chair of the council, Professor Tracey Moroney attended and presented that.

COMMISSIONER ATKINSON:  Do you know what the outcome, if any, of that was?

MS EDWARDS:  I think the outcome was provided by the Department, that there would be ongoing discussions with regard to how to progress this issue forward.

COMMISSIONER ATKINSON:  That is it?  That is the outcome?

MS EDWARDS:  Yes, so there were presentations from various different professions in different groups, and the Department were intending to take it forward.  They were intending to have further discussions around how this could be done, whether it was done with a national competencies framework, that they were going to have further discussions regarding that.

COMMISSIONER ATKINSON:  Thank you.

MS WRIGHT:  Commissioner, we will receive some evidence from Professor Trollor about the progress of those roundtables tomorrow.

COMMISSIONER ATKINSON:  Sure.

MS WRIGHT:  Dr Gatling, are you able to explain the link between Registered Nurse or Enrolled Nurse Standards for Practice and the Accreditation Standards?

DR GATLING:  Yes.  What happens is the Nursing and Midwifery Board of Australia, which is the peak body, the registering body for nursing and midwifery in Australia, prepare the standards of practice.  They review those on a regular schedule so the last set were, for nursing were 2016.

Then, following that, ANMAC makes accreditation standards in order to prepare graduates of programs to meet the standards of practice.  So standards of practice first, followed by the accreditation standards.  And so that is the relationship.  The education program prepares the graduate.

MS WRIGHT:  Is it fair to say that neither the standards of practice or the accreditation standards for either group in the nursing profession, that is enrolled nurses and registered nurses, refers specifically to disability in the standards?

DR GATLING:  Yes, that is correct, they don't.  The standards of practice are very broad and they cover things like communication and assessment and allowing autonomy of decision making and involving families and carers and almost very  
broad statements.  But you are correct, they do not refer specifically to any population.

MS WRIGHT:  There is one exception to that, isn't there, and that is Aboriginal and Torres Strait Islander peoples   

DR GATLING:  Yes, sorry, yes.

MS WRIGHT:  --- and the accreditation standards require curricula to incorporate that content?

DR GATLING:  Yes.

MS WRIGHT:  A lot of flexibility is given to the education providers to determine their own curricula?

DR GATLING:  Yes, this is for the Bachelor of Nursing programs leading to a registered nurse, a very --- university   can see what these standards of practice are and really largely make up their own minds about the flavour of education that will lead to that.

However, that is not the case in the vet sector where the enrolled nurses come from, so the Diploma of Nursing is governed by a national training package which has core units in it and electives.  So it is very specific and so every enrolment around the country will have done the same program, give or take one of the electives.  The disability is included, I actually thought you might ask that.  So I did look up and I can see that in the core units, there is   I will not read out the number   but there is one of the units specifically, it is called Work with Diverse People, and specifically it refers to working and learning about how to care for people with a disability.  So that is in the enrolment sphere.

MS WRIGHT:  That is the mandatory part of the enrolment package for enrolled nurses?

DR GATLING:  I would imagine.  I have not looked up the content of all of those, but I have a very strong feeling because there are other units I think it comes up with as well.  It is very specific.  It is quite prescriptive actually.

MS WRIGHT:  Every person who qualifies as an enrolled nurse receives that training package, is that correct?

DR GATLING:  Yes that is right.  Because the ANMAC Accreditation Standards for the enrolled nurse, one of the standards is that the program is derived from the training package, so that is how those two things are linked.

MS WRIGHT:  In terms of registered nurses, do you think the accreditation standards and the standards of practice give too much discretion presently to  
education providers, which means   there are two parts to my question   that disability content is not sufficiently covered across the board?  The audit seems to suggest that might be the case.

DR GATLING:  Yes.  I think we have just published in 2019 the latest version of the ANMAC Accreditation Standards for Registered Nurses, and in that I think we have done better.  Well, one of the things that guides the making of standards is this idea of right touch regulation where it is   they are outcome focused rather than input focused, and that direction has come from the review of --- the NRAS Review which said you should not be prescriptive, you have to write a broad statement about what a program should have, and then the provider has to match that.  And I think we   if I can just read this bit out from   it is in my statement.  But in the Registered Nurse Accreditation Standards 2019, the latest hot from the press version says:

The program's content and subject learning outcomes embed principles of diversity, culture inclusion and cultural safety for all people.

And what we did in these standards is because we   because that is so broad and does not give much direction, we as ANMAC have been very prescriptive really in what we wand to see as evidence.  So we have made an Essential Evidence document, and then in that document they   we have made templates where an education provider when showing us their program for accreditation must map where all elements of this come in into each of their units of competency and in their assessments and in their expected outcomes.

If I can refer to Flinders which has recently undergone accreditation, I just checked to see what was in theirs, and they had very nicely, I thought, in their mapping documents, had shown us exactly where disability was in their program, because they --- for 3.7, which is that one I have just read out.  I have not checked across the board, but my feeling is that the new standards will drill down much more into what this diversity means.  It means caring for   because person centred care is the core of nursing.  And it is for every person.  So people with disability are   make up every person, that definition.

MS WRIGHT:  Does the ANMAC Essential Evidence document refer to content on cognitive disability?

DR GATLING:  No, it doesn't.  It says --- what limits is to include a definition and explanation of what cultural diversity and cultural safety principles are and how that translates into subject learning outcomes, and that is when we would see that when the submission comes forward from an information provider, what they consider to be cultural diversity.  Then the content mapping template which I referred to before has subject learning outcomes and program content with examples preparing to practise cultural safety at work with people from diverse backgrounds, but we do not mention, I must admit, cognitive disability, although we give some examples.  And this document can be changed at any time because it is a working document   

 
CHAIR:  Can I be clear as to which document you are talking about ---

DR GATLING:  I'm talking about the Registered Nurse Accreditation Standards 2019.

MS WRIGHT:  Which is Tab 11.

CHAIR:  I have that, and section 4 of that document has the Registered Nurse Accreditation Standards.  Is that what we are talking about?

MS WRIGHT:  I believe it is at page 16, Commissioner.

Was it Standard 3.7, Dr Gatling, you are referring to under Standard 3 relating to programs of study?

DR GATLING:  Yes.  You might not have   there is an accompanying document which is the Essential Evidence, and that is where I'm talking about the templates where this would were stepped out by an education provider.  But you might not have that.

COMMISSIONER ATKINSON:  In that Essential Evidence document, does it refer to people with disability or people from diverse backgrounds?

DR GATLING:  Diverse backgrounds.  It is not specific.  Dealing with people with disability.

CHAIR:  I take it you would agree with me if one reads Section 4, Registered Nurse Accreditation Standards, it really contains nothing about people with disability, at least a reader could discern from that, other than a very general statement about the importance of understanding diversity?

DR GATLING:  I'm sorry.  Which is section 4?

CHAIR:  I think it is the one you were referring to, starting on page 14 of the document going to page 17 and it contains five standards.

The paragraph you were referring to, as I understand it, was paragraph 3.7?

MS WRIGHT:  Is that right, Dr Gatling?

DR GATLING:  We usually just refer to the five standards, but I agree with you, so if it says Section 4 somewhere then I would say you are right.

MS WRIGHT:  The document, Dr Gatling, Registered Nurse Accreditation Standards 2019 at page 14 has a heading with a "4", Registered Nurse Accreditation Standards and the Standards then follow.  Under that heading?

 
DR GATLING:  Yes.  Four.  Thank you.

MS WRIGHT:  Thank you.  Do you agree with the Chair's comment that the Standards overall do not contain any reference to disability, specifically?

DR GATLING:  Yes, totally, I agree.

COMMISSIONER ATKINSON:  Were they standards you said could be changed or was it another document you said could be easily changed?

DR GATLING:  Changing the standards is quite   the standards themselves   is a bit of a mission because they have to have widespread stakeholder consultation and stuff.  But the Essential Evidence, which is what I was referring to, where we say what ANMAC accreditation teams need to look at to see if an education provider's submission has met the standards, that can be   and that is the purpose of it, we thought   was that when there were changes in legislation or changes in thinking, or Royal Commission's like this, we can add bits to that because it does not change what the standard is, which says "Look after people from diverse backgrounds".  We can then ask saying, about this, you know, the diverse background which is someone with a cognitive or other disability, where is that in your program?

COMMISSIONER ATKINSON:  Probably it comes within inclusion, doesn't it, if you include all people?  It is not so much diversity of background which usually refers to people from culturally and linguistically diverse backgrounds but actually including everyone, including people with disability even though you do not actually mention people with disability.

DR GATLING:  Yes, all that is definitely possible and it is desirable if there is, as it seems there is, there is a need for that.

MS WRIGHT:  If ANMAC considered it to be of sufficient importance to include an evidentiary requirement in the Essential Evidence document, then ANMAC would in theory support a revision to the standards themselves to refer to disability?  Does that follow?

DR GATLING:  Yes.  ANMAC   what the guiding principle for ANMAC is is safety of the public, and if there is an area where it seems like these standards are not providing safety for the public, then obviously we   the NMBA would ask us to do that because they are the overarching body, and that means we could put that in train.  ANMAC just wants to have nurses who are safe to practise for all people.

MS WRIGHT:  The accreditation standards themselves are ultimately approved by the Nursing and Midwifery Board of Australia, that is right?

DR GATLING:  That is correct, yes.

MS WRIGHT:  I just wanted to ask you about one amendment which was made in  
2018, and that was to amend the Registered Nurse Accreditation Standards to include reference to mental health for the first time.  Is that right?

DR GATLING:  Yes.  Well, that is interesting.  It was   the standards have always talked about national health priorities, and this time   and mental health and aged care, because that is mentioned as well, in those priorities.  It is the first time we have actually said, "Including mental health".

MS WRIGHT:  I see.  So the standard you are referring to is 3.5(b), which requires nursing programs of study to include knowledge about regional and national health priorities?

DR GATLING:  Yes.

MS WRIGHT:  Where does ANMAC find the national and regional health priorities?

DR GATLING:  They are published by the Government, by I think it is probably the Department of Health publish those, and the Bureau of Statistics refers to them.  They include things like chronic health conditions, cardio conditions, stroke, mental health, things like that.  Disability is not in them at this time.

MS WRIGHT:  But to your knowledge, cognitive disability is not a national priority?  But that was the pathway for including in these Standards a reference to mental health?

DR GATLING:  Yes.

MS WRIGHT:  Did that lead to change in universities' curricula, or is it already happening?

DR GATLING:  Actually, it was already happening.  We looked at all programs.  Every single university had a unit on mental health in their program already.

MS WRIGHT:  I see.

COMMISSIONER ATKINSON:  May I ask a question?  Thank you.

In your Accreditation Standards, Standard 3 is the one that deals with diversity, that is 3.7?

DR GATLING:  Yes.

COMMISSIONER ATKINSON:  Then if you go to the Essential Evidence document, you deal with 3.7 pretty briefly, fairly briefly, including, you say, that examples of diverse background are ethnicity, sexual identity and religion.  So even when you give the examples in the evidence document you do not refer to disability at all, let alone cognitive disability.  Is that correct?
 

DR GATLING:  Yes, that is correct.  But we could.

COMMISSIONER ATKINSON:  Indeed.  Thank you.

CHAIR:  There is in fact one reference to impairments that one can discover, under Standard 1, 1.6, the education provider, this is in the Accreditation Standards, not the Essential Evidence document, 1.6 says:

The education provider last to have in place processes to manage students with identified impairments that may place the public at risk.

So the only reference to impairment is the possibility that somehow a student with impairment might create a risk to patients.

DR GATLING:  Yes, that is right.

CHAIR:  Perhaps some careful reassessment might be very sensible.

MS WRIGHT:  Professor Wilson, you have said that PANDDA's position is that there should be a national approach to mandatory education and training in intellectual disability, specific content for all healthcare professionals.  Now that obviously includes the nursing profession?

A/PROFESSOR WILSON:  Of course.  Nurses are the largest part of the entire health workforce, by far.

MS WRIGHT:  And have the greatest contact with the people in the health sphere?

A/PROFESSOR WILSON:  Yes, allied health professionals and doctors may spend 5 or 10 minutes with a patient.  The nurse may spend their entire shift with a patient, yes.

MS WRIGHT:  How would such a national approach to mandatory education and training be achieved, in your view?

A/PROFESSOR WILSON:  Well, I think number 1 it needs to be something that is mandated, and needs to be mandated in the ANMAC Standards because the schools of nursing will not put content --- they literally follow that ANMAC framework when they put their curricula together.  I think that focussing on vulnerable populations or marginalised populations is fraught with difficulty.  I think that it is far more sensible and logical to focus on health disparities, and --- so for example, who is a vulnerable population might require a values judgment whereas if you are looking at who has disparate health outcomes is grounded in the research data which Julian Trollor and a whole bunch of others have been reporting, hence, while the health needs of Aboriginal and Torres Strait Islanders have been included in the ANMAC standards because of their health disparities.
 

So I think that using vulnerable and marginalised is fraught with difficulty.  I also think that using a broad descriptor of "cognitive disability" is also fraught with difficulty because "cognitive disability" includes people with acquired brain injury, people with dementia, people with degenerative disorders, stroke and so on, people with intellectual and developmental disability, it is a life long impairment, and the sorts of issues that they face are very, very different.

But the way that you might communicate with someone with intellectual and developmental disability is also very, very difficult to, say, someone with brain injury or a transient cognitive impairment, where, for example, issues such as memory, attention or mood might be the primary issues, but people with intellectual and developmental disability, it would be very, very different.  So I think they are two critical issues that PANDDA believes would need to be absolutely clear, that it would need to be mandated around intellectual and developmental disability and, not a broad de differentiated "cognitive disability".  So I think if it was mandated by ANMAC then the schools of nursing would include it in their curriculum, just as they have done with the health of Aboriginal and Torres Strait Islanders.  And I think that also an assumption that intellectual and developmental disability is a part of cultural and identity and diversity, that is also fraught with difficulty because I would not say that most Australians would think that intellectual disability is part of someone's cultural diversity.

MS WRIGHT:  It is also placing a burden on those general principles which   to generate content in an educational setting which is ---

A/PROFESSOR WILSON:  That is correct, as Dr Gatling mentioned earlier, schools of nursing can put   it is fairly open in terms of what they include in their content, and so if you say in the ANMAC Standards there needs to be a focus on vulnerable populations, then one school of nursing might focus on the homeless, because that might be an area of academic expertise, another school of nursing might focus on sex workers, or injecting drug users, another school might focus on men from rural areas who are committing suicide at high rates.  So it is open to interpretation as to who is vulnerable and when.

COMMISSIONER ATKINSON:  Associate Professor Wilson, if I can just throw you a curveball on the cognitive disability question.  What about people with autism or autism spectrum disorder that can be included in the broad generalisation of "cognitive disability" but don't fall neatly within intellectual disability or developmental disability, or the others that you mentioned?  Should they be included in this regime?

A/PROFESSOR WILSON:  Yes, absolutely so, when I refer to people with intellectual and developmental disability, you can have a developmental disability such as autism but it does not mean you have intellectual disability.  However, intellectual disability is a developmental disability, the difference being we are talking about something that is across the lifespan.  We are not talking about  
something where you acquire a disability when you are 45 and have had a car accident and now have a brain injury, or you are 52 and suddenly had a stroke.

COMMISSIONER BENNETT:  (Inaudible) in the NDIS?

A/PROFESSOR WILSON:  Sorry I can't hear you.

COMMISSIONER BENNETT:  You have received a grant from the NDIS, with Professor Cashin to building the capacity of nurses to deliver mainstream hospital integrated health services to people with intellectual disability and autism spectrum disorder.  I have three questions in relation to the evidence you provided at paragraph 39 onwards.

Firstly, are you also looking at the settings in which those people might live?  You have heard that people with a cognitive disability have poor outcomes but we have also heard they are even poorer if they live in group homes.

The second question goes to that you are hoping that nurses might voluntarily take this up and that you are approaching networks that they might do additional online work.  Secondly, is this one way and one type of investment that is needed to continue to improve nurses' ongoing continuous training and understanding of the change in issues in this area?

A/PROFESSOR WILSON:  Okay.  So in answer to your first question in terms of the diverse settings that people with intellectual disability and developmental disability might live.  We do not provide content on that --- this is where someone with intellectual and developmental disability presents into the primary or tertiary health system where nurses are already working, so whether it's the Emergency Department, a GP clinic or an outpatients clinic.  So these are nurses that are out there, they have done their training, they are working as nurses in these mainstream environments.  So in terms of where people live, we may include some content because the project is only six months old, it's a three year project and we are writing the content at the moment.  So we may include some descriptive content that may describe how there are different outcomes depending on the context that a person lives, however it is about how do nurses who have a patient with intellectual disability or autism on their shift, how do they then better work with that person?  So that is the focus of the research project.

The second point around the voluntary nature, yes, we hope that because we are offering the carrot of continual professional development opportunities, so all nurses have to, when they renew their registration every single year, need to make a declaration that they have undertaken continuing professional development, or CPD.  So by offering free online free CPD opportunities, and also by networking with our partners, who is the College of Emergency Care Nurses, the College of Critical Care Nurses, the Primary Nurses Association, and the Australian and Nursing Midwifery Federation, we are hoping we can utilise their network to reach out to several hundred thousand Australian nurses, and we are hoping to entice them with free CPD  
opportunities.

The third point --- you are going to have to remind me what the question was, sorry?

COMMISSIONER BENNETT:  The third point was, do you think that more of this type of investment is part of ongoing professional development?  Because the nature and issue emerging changes, is this what need to be continually invested in on a regular basis?

A/PROFESSOR WILSON:  I guess a couple of things.  The first is that   this is remedial work because there are many, many nurses over many years who have never learnt a anything about intellectual disability and autism, and the research data about nurses that work in mainstream health settings are that they struggle to communicate with people with intellectual disability and autism, and they struggle to understand how to work effectively with families and other carers, and so it is remedial, I guess, in that sense.

Going forward, I guess let's imagine that we have a national workforce that has undergone mandatory training as a part of their undergraduate program, then training like this could still be offered for nurses who may   are still interested in learning more about intellectual and developmental disability.  So for example, if you are a nurse working on a neurology ward you are probably more likely to encounter patients with intellectual and developmental disability than, say, if you are a nurse working in the antenatal clinic, for argument's sake.  And so therefore, if you are exposed to more people with intellectual disability in your day to day practice, you will then potentially want to know more.

The final piece of the jigsaw puzzle that is also currently missing in Australia is that there is currently no nurse specific postgraduate program for nurses who want to specialise in working with people with intellectual and developmental disability, and so in terms of building the capacity of these nurses that do work in this area currently, there is a gap there.

CHAIR:  That is precisely the question I wanted to ask, taking it back a step.  Assume I am enrolled in a course or wish to be enrolled in a course, and I wish to be a nurse specialising in caring for people with intellectual disability.  What do I do?

A/PROFESSOR WILSON:  Well, there are a very small number of postgraduate courses that are badged around disability and inclusion.  For example, Deakin University offers one, Melbourne University offers one.  They are more rights based postgraduate programs, they are not health based and they are not nurse specific.  So if you were a nurse that wanted to specialise in this area, there is nothing at the moment that specifically caters for you.  So it is a real limit for those nurses that want to specialise in this area.  They would potentially enrol in a generic Masters of Nursing Leadership, for example, then may choose to do some of their assessment tasks specific to people with intellectual disability, but in terms of learning much more, for example, about many of the genetic causes of intellectual disability,  
understanding how certain genetic disorders predispose people to a certain range of health problems, that can also be predictable at various points in the lifespan.  That needs to be very   a postgraduate program that is very health and very nurse specific as opposed to being based inhuman rights.

CHAIR:  So there are no courses of that description currently offered, I take it from what you say?

A/PROFESSOR WILSON:  No, there is not.  Not in Australia.

CHAIR:  Can I ask another question, please, about the undergraduate courses.  Am I right in assuming that there is very little choice of subjects in undergraduate nurse degrees?

A/PROFESSOR WILSON:  I think if you were a prospective student looking at a range of different universities, you could go on their websites and certainly different universities offer different flavours of undergraduate programs and you might see one that you might feel would appeal to you more than another.  I do not know that there are many students that undergo that decision making process.

CHAIR:  No, I'm more concerned with once you are in a course, I take it that there is not much choice of subject within that course?

A/PROFESSOR WILSON:  No.  You undertake what is prescribed.  But there is the opportunity for a small number of elective units of study, and then that depends on what the university offers also.

COMMISSIONER ATKINSON:  Professor Wilson, looking at it from a nurse's point of view, if you are a registered nurse or a recently graduated student, and you had no training at all on how to properly care for people with intellectual disability or autism, it must be very stressful in the workplace trying to learn just from your own devices how to do those things properly.

A/PROFESSOR WILSON:  Absolutely, yes, and that is what the research data points to as well, that nurses struggle in this area.  Yes.

MS WRIGHT:  Professor Wilson, do you consider that your project, developing a training package to build capacity of nurses in practice to deliver care to this patient population, could contribute to the development of a competency framework?  You have said there should be a national approach to mandatory education, and Counsel Assisting have put forward as a proposition number 1 in the document that I think you have received that there be a competency framework developed which identifies the capabilities that should be taught by education providers?

A/PROFESSOR WILSON:  Yes.

MS WRIGHT:  Do you think your work developing content for nurses in practice  
could contribute to that?

A/PROFESSOR WILSON:  Yes, I believe it would contribute to that, but it would only be one piece of the puzzle.  So I --- that is myself and Professor Andrew Cashin as academics who are leading that project --- would have a certain point of view.  PANDDA, who is the Professional Association of Nurses in Developmental Disabilities would obviously like to have a seat at the table.  People like Julian Trollor, but also most importantly people like Corey who you heard from earlier on.  People like Virginia Howie who you will hear from tomorrow who is a parent with someone with intellectual disability.  So I think it should be an approach that does not just rely on so called experts.

MS WRIGHT:  I saw you nodding, Professor Brebner.  You agree that people with cognitive disabilities should be included in the design of content that is caught?

PROFESSOR BREBNER:  Absolutely agree.  Those people who have lived experience of disability themselves have expertise and knowledge of the experience and should be than a equal partner in the process of co designing a framework.

MS WRIGHT:  Ms Edwards, I just have one more question for you.  Do you agree that there is no reason to believe that the 50 per cent of nursing schools that were not audited by Professor Trollor and his colleagues had performed any better than those that were audited in relation to healthcare of people with cognitive disability?

Sorry, I think you will have to change your setting.

MS EDWARDS:  Sorry.  No, I don't believe there is, if they did not answer the audit and provide that information, then there is no reason to believe that they would do any better.

MS WRIGHT:  Thank you.  Those are my questions.

COMMISSIONER ATKINSON:  I should say, for the sake of completeness, I mentioned the stress on the nurse; I cannot imagine what stress it puts on the patient if a nurse with no training is trying to care for a person with intellectual disability and autism.  It is stressful for the nurse, but it must be even more stressful for the patient, and cannot imagine that leads to a good outcome for anyone.

Does anyone want to comment on that?

A/PROFESSOR WILSON:  The only thing I would add to that, is their family, their parents when they are not being listened to and they can see mistakes being made, yes.

COMMISSIONER ATKINSON:  Thanks.

CHAIR:  Commissioner Atkinson, any further questions?
 

COMMISSIONER ATKINSON:  No, thank you.

CHAIR:  Thank you very much Associate Professor Wilson, Professor Brebner, Ms Edwards and Dr Gatling for giving evidence.  It has been a very instructive session and I do hope that in due course it will lead to some useful outcomes.  Thank you very much.

THE WITNESSES WITHDREW

MS WRIGHT:  It has been suggested that we adjourn until 2.45.

CHAIR:  Since it has been suggested, it is determined that we will.

MS WRIGHT:  Not by myself.

ADJOURNED    [2.21 PM]

RESUMED    [2.45 PM]

CHAIR:  Yes, Ms Eastman.

DR DINESH PALIPANA

MS THEANNE WALTERS

PROFESSOR RICHARD MURRAY

PROFESSOR INAM HAQ

MS EASTMAN:  Thank you, Commissioners.  We come to the final panel for today, and we have four participants on the panel.

Dr Dinesh Palipana, who you may recall gave evidence to the Royal Commission at part of Public Hearing 5 concerning COVID 19 and the impact on people on disability, will join us.

 
Ms Theanne Walters, I can see in the corner there, the deputy CEO of the Australian Medical Council, and she has prepared a statement for you, Commissioners.  You will find that in Tender Bundle A behind Tab 61, so it's Volume 2 of Tender Bundle A.

Then I can see Professor Richard Murray --- if I can ask you to signal to let the Commissioners know   who is appearing for Medical Deans of Australia and New Zealand, and a copy of the Medical Deans statement you will find behind Tab 53 of the Tender Bundle Part A in volume 1, it's the final document in that folder.

And Professor Inam Haq, who I can see in the corner, who is the Associate Dean (Education) at the Faculty of Medicine and Health at the University of Sydney, and a copy of his statement is at Tabs 14 and 15 of Tender Bundle A in Volume 1.

This panel is going to focus on three of the propositions, Propositions 1, 6 and 8, and I ask that those proposition also come up onto the screen.

Proposition 1, Commissioners, you have heard some discussion on during the course of the evidence today.  Proposition 1 is under the heading "Competency Framework".  You will see that as Counsel Assisting, we have advanced four parts to that proposition.  First, a competency framework for health professionals should be developed promptly including for medical practitioners, nurses, dentists, clinical pharmacists, psychologists and relevant allied health professionals.

So that is the competency framework.

Then, secondly, to develop a competency framework, there should be consultation with people with disability and a range of stakeholders.  So that is the consultation aspect.

Thirdly, that the competency framework should specify core knowledge, skills and attributes required by health professionals to equip them to provide quality healthcare to people with cognitive disability.

Then the fourth part is a suggestion that the competency framework contain guidance on four particular areas which you will see set out on the screen there.  That is: fundamentals within all training and education, education at different levels, education that is tiered to specificity and complexity and where to find teaching resources.

Now, relevant to Proposition 1, the two other propositions that we want to focus on with the panel this afternoon are Propositions 6 and 8.  So can I just ask that those Propositions come up.  If we look at Proposition 6 first.  The focus is on university and vocational education, and this is curricula review and reform.

You will see that what we have proposed is that the curriculum developers should review and revise curricula for primary medical programs, and that should enhance  
or incorporate content concerning the healthcare of people with cognitive disability.  And we have made some suggestions if a competency framework is developed.

Then Proposition 8 comes to the accreditation standards, and our proposition is that accreditation authorities should review and revise the standards to ensure minimum competency in providing health care with people with cognitive disability to ensure that they are adequately addressed.

So those are the propositions I want to explore with our witnesses this afternoon.

CHAIR:  Before you do that, could I please thank those who have come along this afternoon, Ms Walters, Professor Murray, Professor Haq and Dr Palipana.  I think we should congratulate Dr Palipana, who has been named, as I understand it, Queenslander of the Year.

MS EASTMAN:  You've stolen my thunder, I was saving that up in my introduction.

CHAIR:  Yes, I'm accustomed to doing that and we will continue to do as long as the Commission lasts.

Congratulations, Doctor Palipana, and thank you also for the help you have been giving this Royal Commission, which we greatly appreciate.

DR PALIPANA:  Thank you so much.

MS EASTMAN:  I want to start by providing a short overview and summary of the evidence that has been provided by the witnesses participating in the panel this afternoon.  I may not do justice in the summary to the very extensive and detailed statements that have been provided, but let me start with the Australian Medical Council.  It is the accreditation authority for medical education and training.  It sets accreditation standards for medical degrees and assesses medical schools and degrees against those standards.  The AMC has accreditation standards for both university level education and for specialist programs of the college also.  We will explore tomorrow the colleges; our focus at the present time is on the university.

Now, the standards are then approved by the Medical Board of Australia.  Looking at the accreditation standards, other than a reference to medical students with disability, there is no reference to people with cognitive disability in the accreditation standards.  As we saw on the previous panel, nursing has its own accreditation standards, and each profession expresses its accreditation standards differently.

The Department of Developmental Disability Neuropsychiatry at the University of NSW has recommended minimum capacities in intellectual disability knowledge and skills should be included in any future revisions of accreditation standards for medical practitioners.  And you will find a copy of that article in Tender Bundle B behind Tab 26.

 
If this recommendation was accepted, it would have the effect of mandating curriculum changes by education providers.  This morning you heard from Dr Jane Tracy.  She gave evidence, but in addition to her oral evidence she has also provided to the Royal Commission an article in which she argues that accreditation and regulatory organisations should mandate universal medical education in the area of cognitive disability.  A copy of that you will find in Tender Bundle B behind Tab 41, and the specific recommendation is made at page 28.

Dr Tracy considers that without these bodies being onboard, the system will remain where it is, and that is that cognitive disability content is either not included or it can be easily dropped out of curriculum, depending on other priorities.

We have this afternoon the opportunity to hear from Medical Deans Australia and New Zealand.  It comprises all of the 22 universities in Australia and New Zealand who have an accredited medical program for professional entry level medical education training and research.

As I read their statement, this peak body does not support taking a mandatory approach to defining curriculum in this area.  But we do know that Medical Deans and their members play a key role in facilitating collaboration across medical schools and other stakeholders in medical education and training.

You have a copy of the Medical Deans statement that’s Tab 53 in Tender Bundle A Part 1.  The Medical Deans state that accreditation standards and its own strategic plan are focused on high level, and not on particular patient populations or groups, and therefore do not specifically refer to the teaching of healthcare for people with cognitive disability.

There is one exception in terms of identifying a particular population, and that is in the area of Indigenous health.  And it is interesting to note that it was the Medical Deans who led the development of the first curriculum Indigenous framework back in 2004.  Medical Deans, as I understand it, will tell you that medical graduates are still in an early stage of their careers and the focus should be on teaching the core elements of patient centred care and socially accountable practice, and the Medical Deans refer to the pressures on medical school curricula to constantly increase the time and focus on specific topics, and I want to explore that issue this afternoon.

So the question for this panel is, if there is to be a change in the curricula of medical schools across Australia, how can this be done?  What can be done?  And if there is not to be a change, what are the alternative ways to enhance education content and increase consistency in teaching the across Australia to better support health outcomes for people with cognitive disability?

We know some universities recognise the need for a greater and deeper focus on vulnerable patient groups, and I'm going to ask Professor Haq in due course about his statement which identifies the approaches taken at the University of Sydney, and as I understand it, an acknowledgement that more could be done to enhance content in  
relation to people with cognitive disability.  But before I start, I want to take you back to some evidence that you heard at the hearing in Homebush in February, and you may remember the evidence of Tara Elliffe, and I will replay some of her evidence now.

[VIDEO RECORDING PLAYED]

MS ELLIFFE:  One day in 2018 I was feeling unwell and had a pain in my stomach.  I went to the GP with my father; but it wasn't my usual GP.  This doctor asked me how my pain was, and I was feeling gentle.  The doctor told me to go to the hospital.  I went to the hospital with my dad.  When I got to the hospital, I was in a lot of pain.  I was --- I had to sit outside for about ten minutes before I went into see the doctor who I was --- who saw me.  I had blood tests, X ray and scans.  I saw a lot of different doctors.  I felt like a yo yo going for the test.

MS EASTMAN:  Okay.  So you want --- do you want to keep reading?  If you want to change your mind, just let me know.

MS ELLIFFE:  I keep reading.  Thank you.

MS EASTMAN:  Keep reading?  Okay.

MS ELLIFFE:  My head was exploding from all the noise and different people.  It was building and crushing down on me.  My stomach was in so much pain.  It was like a jackhammer was in my stomach.  The big doctor came in to tell me that I was ready to go home.  This didn't look at me at all.  He just looked at my dad and said, "What's her problem?"  Mum asked me to point on her back
where the pain was.  I pointed to her shoulder.  Then the doctor ordered another ultrasound.  The lady who did my ultrasound was good.  She explained what she was going to do and said:  Sorry if it hurts."  I had an operation the next day.

After the operation, I was in hospital for what I felt like ages.  It took a bloody long time to get home.
Every morning in the hospital I would wake up at about 4 o'clock am in the morning because I was in pain.  I would call out to Mum, "I need painkillers now."  I was hurting again.  I had to press the button to call the nurse, but she would not give me medication.  I needed my mum and my dad to be there to help to get the painkillers and feel safe.  I was in pain, just wanted to go home.  I don't ever want to go back to a hospital again.

I have a lot of things that I think doctors and hospitals can do better.  Listen carefully to people with a disabilities; ask simple questions; use pictures to help people understand; answering people's questions; talk to me and not my parents; have documents in Easy Read.  Also, think doctors and nurses should have disability training.  Any disability training would be good, and to have 30 people with a  
disability doing same of the training.  Mum has worked in hospital, so I have been to hospital before.  But some people have never been to a hospital.  It would be good if people with disability could have a tour in the hospital when they are well.

MS EASTMAN:  All right.  And then over the page, one more bit to read.

MS ELLIFFE:  Thank you.  If people with a disability can have a tour of a hospital, they would know
what to expect if they had to go to the hospital in emergency one day.

MS EASTMAN:  Can I check, is there anything   

[VIDEO RECORDING ENDED]

MS EASTMAN:  Thank you again to Tara Elliffe for sharing her account and replaying that.

EXAMINATION IN CHIEF BY MS EASTMAN

MS EASTMAN:  All right, Dr Palipana, can I start with you.  You are now a senior resident working in a busy Emergency Department in a hospital in Queensland?

DR PALIPANA:  Yes, Senior Counsel.

MS EASTMAN:  And you can bring a unique perspective on the training and education of medical practitioners and health professions as a person with lived experience with disability?

DR PALIPANA:  Yes, and I must apologise for my background and environment, it is a bit noisy, the timing.

CHAIR:  Some of it is actually quite entertaining.

DR PALIPANA:  Thank you.

MS EASTMAN:  You are currently a senior house doctor working in emergency at the Gold Coast Hospital?

DR PALIPANA:  I am.

MS EASTMAN:  You have worked in this service since you started your career as a medical practitioner since about January 2017?

 
DR PALIPANA:  Yes, that's correct, Senior Counsel.

MS EASTMAN:  You are also a lecturer and a researcher at the Griffith Institute and Menzies Health Institute of Queensland respectively?

DR PALIPANA:  Yes.

MS EASTMAN:  You hold a Doctor of Medicine from Griffith University?

DR PALIPANA:  I do.

MS EASTMAN:  For reasons --- I won't ask you to explain but you also hold a Bachelor of Laws from Queensland University of Technology, and a couple of months ago you were admitted as a legal practitioner in the Supreme Court of Queensland?

DR PALIPANA:  I was, Senior Counsel.

MS EASTMAN:  You are also an ambassador for Physical Disability Australia?

DR PALIPANA:  That's correct.

MS EASTMAN:  You are a Member of the Inclusive Workplace Committee for Commonwealth Treasury?

DR PALIPANA:  Correct.

MS EASTMAN:  You are a member of the Scientific Advisory Committee of the Perry Cross Spinal Research Foundation?

DR PALIPANA:  Yes.

MS EASTMAN:  And you are the doctor for the Gold Coast Titans Physical Disability Team?

DR PALIPANA:  That is correct.

MS EASTMAN:  And you were nominated for and awarded Queenslander of the Year this year?

DR PALIPANA:  I was very humbled to have been, yes.

MS EASTMAN:  You have also done some work with Medical Deans Australia, and as I understand it, you have been part of a working group to develop a consultation paper on Inclusive Medical Education, Guidance on Medical Program Applicants and Students With Disability, and the consultation paper was published in November this year?
 

DR PALIPANA:  That is correct.

MS EASTMAN:  You wanted to make it clear that any views that you discuss in this course of your evidence today don't represent any of the organisations to which I have referred, but they are based on your personal views and experience.  Is that right?

DR PALIPANA:  They are, Senior Counsel.

MS EASTMAN:  Okay.  So let me start.  How much of your training --- sorry, your education as an undergraduate involved learning about people with cognitive disability?

DR PALIPANA:  It was minimal, Senior Counsel.  We learned about the medical aspects of some of the conditions such as Down syndrome, but due to the depth and breadth of medical curriculum, specific training around caring for patients with disabilities was minimal.

MS EASTMAN:  Have you had any training on the job over the past few years that you have worked in the Emergency Department?

DR PALIPANA:  I have not.

MS EASTMAN:  Have you had occasion to treat any patients coming into emergency who has presented with an intellectual disability or cognitive disability?

DR PALIPANA:  I have, Senior Counsel.  We frequently treat patients with cognitive disability and intellectual disabilities in our Department, and over my time I have had the privilege of treating many patients with such disabilities.

MS EASTMAN:  So, have you had the adapt the way in which you communicate with those patients or explain concepts that allow the patients to give consent to particular medical procedures, and if so, what have you had to do?

DR PALIPANA:  Yes.  I think it is a very tricky situation because when you normally treat a patient, gaining the history is one of the most important parts, and taking a comprehensive and detailed history about their presenting issue helps guide the remaining treatment and investigations that you will carry out.  So in the event that a person is unable to clearly explain what kind of pain they are having or what kind of symptoms they have been having, it makes the rest of the consultation complex, and there are some critical questions that you sometimes need to ask that might really change the course of management.  So I think one of the most complicated parts of it has been to make sure that we are getting the right history and a detailed history that points towards a problem --- or at least allows us to exclude any life threatening issues that might be occurring.

 
MS EASTMAN:  Many witnesses have told us at previous hearings that in an Emergency Department the doctors might not speak to them but speak to their parents or their carers, and has that been your experience in being able to take a history?

DR PALIPANA:  I suppose my approach has been coloured by my own experiences as a patient, but I often will talk to the patient first, and then with their permission and if they are happy I will talk to their caregiver or the parent as well to gain additional information about what brings them there.

But, even me as a previously medical student and as a medical graduate, I have instances where I have had difficulty navigating the medical system myself, but I have had the privilege of being health literate so I have been able to get about things the right way.  But certainly there are instances where you can be treated a little bit differently by virtue of having a physical or cognitive disability.

MS EASTMAN:  Thank you for that perspective.  I will come back to you in a motion.

Commissioners, I omitted to say that before coming into the hearing room that all of our witnesses have given their oaths or affirmations.  I want to introduce and come to the other members of the panel.

Professor Murray, can I start with you.  You are Richard Murray?

PROF MURRAY:  Yes, that is correct.

MS EASTMAN:  You are the acting Deputy Vice Chancellor in the Division of Tropical Health and Medicine at James Cook University Townsville.

PROFESSOR MURRAY:  That's correct.

MS EASTMAN:  You are the President of Medical Deans Australia and New Zealand?

PROFESSOR MURRAY:  That is correct.

MS EASTMAN:  So you are speaking on behalf of the Medical Deans of the 22 universities that conduct undergraduate or immediate graduate medical programs in Australia and New Zealand?

PROFESSOR MURRAY:  Yes, that is the case.

MS EASTMAN:  Can you tell us a little about what Medical Deans is and what it does and what are the objectives of the deans having this organisation?

PROFESSOR MURRAY:  I guess they are a community of practice among health  
professional entry level programs is common, and certainly Medical Deans, previously first established as the committee of   our Council of Deans of Medical Schools, it is a common arrangement and I guess the value in that comes from being able to connect a community of practice across various things, not least of which is the continuously evolving art and science of health professional education.

I suppose that there is development that is to do --- or standards, if you like, of medical education that is about meeting a minimum standard, for instance, that which you would expect coming out of an accreditation system, assuring a minimum standard.  I guess in relation to medical education and training, creating a connection amongst medical programs so that there can be a continuous learning exchange and development of the art and sciences per se of producing entry level doctors is really what that component is about.

There are other point of interest too, including around how we might advance (audio distorted) the conduct amongst medical schools, the development of a cadre of web force for instance, clinical academics to be staffed in clinical education, but certainly central to it all, I think, is the collaboration around the practice of medical education, curriculum, assessment, particular population groups, whatever it might be.

MS EASTMAN:  The Medical Deans have, as you have said in the statement, nine specific objectives.  One of these objectives is to provide leadership in medical education, research excellence and advocacy.  Is that advocacy, advocacy around better outcomes of medical education?  What does that entail?

PROFESSOR MURRAY:  Yes, that is right, I suppose, speaking for and on behalf of the collective of medical schools across Australia and New Zealand in advancing, as I say, the practice of medical education and strengthening of that.  I think by way of example, for instance, over the period of my association, a very strong movement has been around greater awareness of the special responsibility of medical schools as the monopoly providers, really, of medical education and the next generation of doctors, to have an accountability to society, so called social accountability, and how we might better reflect that mandate to align teaching service and research to the priority needs of communities and in partnership with communities.

So those notions, for instance, have been an area of development and advocacy for Medical Deans.

MS EASTMAN:  I have just mentioned a little earlier the recent consultation paper published by Medical Deans on inclusive medical education.  Now, while that does not focus on patients and the care of people with cognitive disability, this is quite a significant step, isn't it, for the medical deans to really say, "We need to have a cohort of medical practitioners who may also be people with lived experience of disability, but if we are going to do that, we need to find ways of ensuring that medical practitioners with disability can practice safely, but at the same time a recognition that medical schools have to make adjustments to enable doctors with disability to be part of the future workforce".
 

So Dr Palipana, i think, has been part of that consultative group, and he brings that perspective of a young doctor with lived experience of disability.
What was it that really triggered the Medical Deans to look at the cohort of doctors and say, "We need to find a way of creating more inclusive programs to have doctors with disability", and then I will come to the other issues around accreditation and patients with cognitive disability, but can I just start with that?  I would be interested in your perspective, and then Professor Haq, I might ask you whether from the University of Sydney you have a perspective on this proposal.

PROFESSOR MURRAY:  Thank you very much for the question.

I think it comes from a broadly held view amongst the leaders of medical schools to see a greater, I guess, broadening of participation in --- from a wider cross section of society in the opportunity to become medical practitioners.  In Australia and New Zealand, as in most of the world, those who manage to get into generally a highly contested process to enter medical school tend to be predominantly from metropolitan locations, for instance, predominantly from affluent and professional background, predominantly exceptionally high achieving in their prior education, often historically in secondary school.  And that such, whilst they are all terribly admirable people, as such often are not really a mirror on society.  So the whole question of being able to have a breadth of participation as part of a social obligation, really, for medical schools is really the driver.  That is one.

The other is, I guess, individual medical schools dealing with, through their admissions processes, requests for consideration or exceptions around various sorts of disability.  And the need, the recognition of the need, really, for providing some sort of guidance advice or a framework to maximise participation.  Clearly, that cannot be open ended, but to try to frame that in a way that   if you like maximising the opportunity to enable participation by people who may be living with various sorts of disability was the intention, and so it is a resource really for the community of practice developed within the community of practice and in partnership with various individuals and agencies, so it is some sort of a guidance to good practice, I suppose, in enabling and broadening participation.

But as I say, it is part of a broader piece which is about maximising opportunities for broad participation in   from across various strata in society in the opportunity to become the doctors of the future.

CHAIR:  Isn't that something that the University of Newcastle did many years ago?  That is, to say broaden their admissions policy along the lines you have just referred to?

PROFESSOR MURRAY:  Indeed.  My colleagues at Newcastle when I think established in the late 1970s --- 1978, I think --- were very keen for instance on admission through interview as well as scholastic criteria as well as undertaking work to demonstrate that that was not a problem in relation to subsequent academic  
achievement.  And indeed, if you look around, James Cook University perhaps is another example where there is a particular emphasis on enabling participation for those who have had a rural or remote background and often educational disadvantage as a result, and also special admission arrangements for Aboriginal and Torres Strait Islander students.  So there is again a quite diverse practice around the country that is perhaps a bit of a theme, but a learning community of practice, I would say, in relation to broadening participation.

MS EASTMAN:  Professor Haq, can I bring you in at this point.  The Commissioners have a copy of your detailed CV, but for those following this particular Public Hearing, you are the Associate Dean (Education) in the Faculty of Medicine and Health at the University of Sydney?

PROFESSOR HAQ:  Correct.

MS EASTMAN:  It is a role you have held since August 2018?

PROFESSOR HAQ:  Correct.

MS EASTMAN:  Before that, you had worked as a co director of the Sydney medical program, and you are yourself a medical practitioner?

PROFESSOR HAQ:  That's right, a rheumatologist.

MS EASTMAN:  It is the day of the rheumatologist, I think, today, we've had the highest number of medical practitioners today.  We will see how we go tomorrow.

Let me come back to Sydney University.  Its admission policy has changed over time, has it not, from an undergraduate course into a graduate course?

PROFESSOR HAQ:  Yes.

MS EASTMAN:  To what extent has there been consideration of applicants to join that program as people with disability?  Has that been at the forefront of what Sydney University has done?

PROFESSOR HAQ:  I think particularly with regards to medicine, if I'm right and that is what you are asking, I think absolutely agree with Professor Murray that we want to broaden the diversity of our intake so that they   it reflects the community that our graduates will go and serve in the future, either whichever part of this country or indeed abroad, as we have students coming internationally as well.  We have participated in university wide broadening access schemes for school entries, certain entry students from economically disadvantaged areas, and also with access schemes for those of Aboriginal and Torres Strait Islander origin.

We do receive applications from students with different types of disabilities, absolutely, and we will look at those on an individual basis, in discussion with them,  
looking at the requirements of the degree and their particular circumstances, and make decisions accordingly.  So I think absolutely we would welcome applications from anyone, absolutely.  And we would look at each individual distinctly based on those circumstances.

MS EASTMAN:  Professor Murray, I want to ask you about a part of your statement, this is page 6 where you say there are currently no specific requirements regarding cognitive disability health content for medical school curricula.  And you say on page 7 that.

We question whether a mandatory approach to defining curriculum elements is most effective.

Am I right in understanding your statement that the Medical Deans would not be supportive of mandatory curriculum contents that covered the healthcare for people with cognitive disability being included in the curriculum?

PROFESSOR MURRAY:  That is correct, but it needs a little nuancing, I think.

What I would say is that medical curricula are inevitably and particularly with the trends, the shortening of medical courses from the traditional six year models to a more common four year model.  The problems of crowded curricula, and in particular the need to avoid a sort of highly atomised prescriptive content, so that there is a mandatory accreditation requirement or other, that essentially sets out medical education, topic by topic, in --- and how that all relates in great detail is in our view to be avoided.

It is not regarded as best practice in terms of medical curricula around the world, which is not to say that there should not be a considerable volume of material and readily available learning resources, of one might even call a syllabus or common models that are shared, but mandating them in a standard curriculum in detail in a single topic area means that potentially, thousands of similar topic areas must similarly be mandated, there is no point at which you would stop with that approach, and by and large that     (overspeaking)    

MS EASTMAN:  Can I put this to you   we know from the data that people with intellectual disability are more likely to die 20 years before their peers without intellectual disability, and we know that the mortality rate for people with intellectual disability is even, and significantly lower than that for Aboriginal and Torres Strait Islander people.  We know the stats indicate that the prognosis for a person with intellectual disability who is diagnosed with cancer is that they are 8 times more likely to die.  Can I ask at what point does the (audio distorted) curriculum have to give way to addressing statistics like that?

PROFESSOR MURRAY:  I would certainly agree with the objective, which is to make comprehensive learning of --- appropriate to the level of an entry level practitioner in being a part of the healthcare of people with providing healthcare for  
people with intellectual and cognitive disability, I agree.  It is more about a means to an end, so I agree with that as an end.  How we get there is perhaps what I will focus on.

There is a lot of very good practice in modern medical education around the country, in my own medical school and indeed in many others, around the specific instruction and supervised experience for students in being able to provide appropriate care to the people with and caring for people with intellectual and cognitive disabilities.  So I think firstly there is good practice that can be shared.

I think there are also good models by which such practice can be disseminated.  For instance, having standard and available high quality learning resources that are updated and are readily accessed by educators, for instance the National Prescribing Service in Australia has a set of standards and modules that are commonly accessed by medical schools and others for standardising and supporting quality learning and teaching around medication use.

So I think that is an example of a means to an end.  I think the other ---

CHAIR:  Would you mind if I approach this from a slightly different angle.  Would you agree that if it is a core competency or capability, depending on which expression you want to use, for a medical graduate who intends to practise medicine, to have an understanding of how to communicate with people with intellectual disability or cognitive disability, to understand the dangers of diagnostic overshadowing and to understand all the other nuances we have heard about in the Royal Commission and I'm sure you are familiar with, concerning the way in which the person with intellectual disability themselves or their families are dealt with in the system?  Is that not part of the core competency or capability of every medical practitioner in 2020, and if it is, then all we need to talk about are the means and ends by which those core capabilities or competencies can be achieved within the medical degree.

PROFESSOR MURRAY:  Look, if I might respond then, I strongly agree with that view, and I think we heard earlier on the testimony from Tara in relation to what it was that she expected, and actually the things that she I think very nicely explained were really about the ability to communicate in a way that is appropriate and tailored to the individual with appropriate use of, for instance, plain language, diagrams, picture, take turning the trouble to speak to the person themselves, not only their career or support person, and having the practised and deliberate skills to be able to do so.

So that is an absolutely core underpinning skill, and I would say it is also shared in common with numbers of other vulnerable patient groups who similarly benefit from that approach to a style of communication with a medical practitioner.  So I think it is not unique, it is just a particular example of the absolute importance of treating each person as an individual with dignity and being able to explain and illicit information in a way that is responsive to that person's needs.
 

I agree also that that must take account of the specific example of the people with a cognitive or intellectual disability.

MS EASTMAN:  Would you accept this proposition   if you say as a starting point that everybody should expect that their doctor treats them with dignity and respect, and if you accept as a starting point that that is the minimum expectation of a medical practitioner, if that same standard is applied to everyone but the person with cognitive disability does not have that same capacity to engage in that communication with the doctor, then treating everybody the same like that just continues and indeed entrenches and a perpetuates that inequality, doesn't it?

PROFESSOR MURRAY:  It does.  Sorry, Senior Counsel, to interrupt, and that is why I would strongly disagree with any notion that communication should be standard.  The whole point is of person centred care, and the great emphasis in certainly all of our teaching and supervision and assessment of person centred care is that it must be specific to the context of the individual, to reflect their values, their understanding, their context, and tailored to that.  That is a set of skills that needs to be practised, learnt and practised.  It is not automatic.

MS EASTMAN:  Dr Haq, do you agree with that?

PROFESSOR HAQ:  I absolutely agree that our students and health students, particularly at University of Sydney, have a lens of patient/client focussed care, and the principles behind that, starting from a junior student to a senior and graduating student, they understand the principles of what that means, and then they apply it in practice in either simulated or real environments under supervision with the absolute requirement that it is bespoke to that person's situation.  That there is not a one level, absolutely.

MS EASTMAN:  So how do the medical students learn that if most of the clinical situations they find themselves in are not for that 1.8 per cent of the population of Australians with intellectual disability, but what might be described as more mainstream population?  How do you teach students to know when and how to adapt communication?

PROFESSOR HAQ:  I think that comes from academic best practice.  I think that is where Professor Murray's concept of the community of practice is really important.  I think we must engage the community as partners in co creation of whatever we decide to come up with, whether it is modules or shared resources.  I think the lived experience is incredibly powerful.  I know our students find that the most powerful learning tool, I could talk about X or Y, but actually hearing from the person about their lived experience of something is   it stays with the student.  I think Tara's testimony ---

MS EASTMAN:  Let me put this to you.  Tara did not have time, when she got to that Emergency Department with a very significant problem, to share her lived  
experience with the emergency doctor before she wanted treatment.  She wanted that to be done when she got there.

PROFESSOR HAQ:  Yes.

MS EASTMAN:  So, sometimes there is not time to wait, is there, to learn the right communication technique?

PROFESSOR HAQ:  But I think that is where   so, coming from a   my job is around training people to graduate to become those entry level practitioners.  We need to give them the tools, (a), to recognise that a person, an individual requires a different level of need or communication and recognise that quickly.  To be able to advocate, I think, very, very importantly, if they see that not happening.  And I think to use the principle and to work quickly in a situation which is often not   it can't be sort of planned for   to get those skills that become automatic.  That is what we do.  So we try to get the skills and understand the reason for the skills, we then can test them in a simulation environment, a safe environment, which can include patients and clients from the community to come and help them, and we can debrief and say what went well, what didn't go well, and in supervised practice they can actually apply those skills absolutely.  At the time they can use the skills they have learnt at the time without having to have had half an hour to think about what to do, and in many cases you can not do that.

In Tara's situation we would hope that our graduates would say "I can now see that Tara has specific needs, I can move to a quiet room, or I can help communicate.  I can talk through what the tests are going to be.  If Tara needs blood, I will explain how that may work", and obviously get her consent, and informed consent to make that happen.  So we want to give student those skills so that when they enter to the workforce they are ready the use them in the real world.

MS EASTMAN:  Dr Palipana, without telling tales on any of your colleagues, but no doubt on the shopfront floor in a busy Emergency Department at the Gold Coast, do you see your colleagues being able to apply these techniques that Professor Murray and Professor Haq have spoken about?

DR PALIPANA:  The emergency environment is a highly dynamic and chaotic environment sometimes, and we have a wide range of medical practitioners that practise, and it can be certainly challenging for a lot of people that come through.  I think the outcomes --- in all honesty, it is variable.  I do like to add, though, that training entry level and junior practitioner with the appropriate skills is important because they end up being the workforce that manages and faces the patients the most.  So sometimes a junior doctor, even in their first or second year, will see a patient, and then they will report back to their senior who may not see the patient sometimes.  So having that junior entry level doctor well equipped to elicit the right information and manage it is really important.

Some of the junior doctors also end up in rural areas where they may be the only  
person around at night.  So really having them equipped to face those situations is important, but from my experience, the outcomes are variable.

MS EASTMAN:  Ms Walters, I will bring you in here.  The Medical Deans say in their statement that they acknowledge that the AMC standards are a significant lever.  They not only bring an approach to about   to bringing about change and improvements, but that medical schools and would be medical practitioners have to be able to meet the AMC standards.  Do you agree that the AMC Accreditation Standards are a significant lever in terms of the development of or changes in curriculum?  And if you want to explain a little bit about how the Accreditation Standards work, I will certainly invite you to do that.

MS WALTERS:  Thank you.  So the standards can be a lever, but I think most importantly standards are an enabler, and by that I mean the AMC's approach has been to set standards that provide the threshold requirements, but without such detail that then they are inflexible for medical schools that want to pursue excellence in an area or have a particular focus on an area.  But also so the standards, medical schools can adapt and change without us constantly changing the standards to keep up with the medical schools.  So I think in relation to   so this is why the standards don't specify core curricula or the content of the medical programs, because knowledge changes all the time and it would be impossible for us to have standards that kept up with that.

MS EASTMAN:  So where does one strike a balance between standards at a general level that gives a university flexibility in following a particular system of values or social objectives, but also ensuring that we are producing a generation of medical practitioners who can respond to the community's needs, including this part of our community whose life expectancy and health outcomes are so disproportionately poor compared to the rest of the community.  Surely that has to be a factor in terms of identifying accreditation standards if you are looking at the purpose of developing a medical workforce that can address these dire health needs?

MS WALTERS:  Yes.  So I think   so I agree, but I think one of the things to think about is how the standards work with other elements of the system.  So the accreditation standards is one part of the AMC's tools, if you like.  We link   we accredit medical programs on behalf of the Medical Board of Australia.  The Medical Board is responsible for the Code of Conduct, for doctors, so that Code sets out expectations and requirements of all medical practitioners.  So we work together in those two areas, so this might be than a area, for example, where the Medical Board's Code could also be augmented.

The Standards, in the past the AMC has issued explanatory notes with its Standards.  The current version of the Medical School Standards don't have that, the Specialist Standards do, and that has been where we have said, "What is an area of particular importance or particular focus in this reading of the Standards?"  So again that is a possibility in terms of the AMC's tools.  So it may be the Standards, it may be the notes, it may be working with the Medical Board, or it may be the overarching  
statements, the graduate outcome statements.

MS EASTMAN:  In terms of the AMC, can I just go back and look behind what the AMC actually is, and it is a body established under the Health Practitioner Regulation National Law, and it has particular functions in relation to accreditation, not just of universities but also the specialist colleges.

And the Accreditation Standards cover a range much issues, not just curriculum but also assessment and other particular outcomes that are sought.  Is that right?

MS WALTERS:  That is right.

MS EASTMAN:  That is a quick paraphrase of the Australian law.  But there are members of the Australian Medical Council, and those members are decided by the AMC Constitution, and you have set that out at page 3 in your statement in terms of membership.

It appears that the members of the Council are intended to cover all relevant people who are involved in the practice of medicine but also the delivery of medical training and education, but also some of the representative bodies like the Australian Medical Association.  Is that right?

MS WALTERS:  That is right.

MS EASTMAN:  Now, the Constitution provides that one person who is an Aboriginal and Torres Strait Islander has to be a member of the Committee; is that right?

MS WALTERS:  Yes.  We have   pardon me.  So we have one person who is an Aboriginal or a Torres Strait Islander, and who is also a registered medical practitioner.  Then we also have a person who is an Aboriginal or Torres Strait Islander who does not need to be a medical practitioner, and a Maori person who does not need to be a medical practitioner.

MS EASTMAN:  And there is no reference to   in the list of members, to a member as a person with lived experience of disability, including intellectual disability.  Do you agree with that?

MS WALTERS:  I do.  There are two people with background and knowledge of health consumer issues, so those are people appointed by an expression of interest from the wider community.  It would be the broader category.

MS EASTMAN:  Have the directors of the AMC ever appointed a person with lived experience of intellectual disability to be a member of the Council?

MS WALTERS:  No, not a person with lived experience of intellectual disability.

 
MS EASTMAN:  Do you know if there has been any consideration of whether a person with lived experience of intellectual disability or an advocate from one of the advocacy groups such as Inclusion Australia or the Council of Intellectual Disability to be considered for membership of the Council?

MS WALTERS:  I do not think it has been discussed in those terms, but certainly the call for expression of interest is a wide one, and applications from such people would be welcome.

MS EASTMAN:  The process of developing the Accreditation Standards is a process that takes a period of time, it requires applications and submissions to be made, and then very carefully assessed.  Is that right?

MS WALTERS:  Yes.

MS EASTMAN:  And the objective is to create a set of accreditation standards that will last for a period of time, indeed, up to 10 years, so that universities and the specialist colleges   I will not forget them   have some certainty about what is expected in the delivery of the education and training and meeting all of the other standards.  That is right?

MS WALTERS:  Yes, the usual period for review of accreditation standards would be five years.  We are at, I think, seven years with the review of the Medical School Accreditation Standards which we have started a review of now, simply because of the developments in the National Registration and Accreditation Scheme, so we paused our most recent review.

MS EASTMAN:  In that five year period there has been a lot of changes, you would agree, in relation to the delivery of disability services within Australia?  We now have the NDIS that has rolled out.  And even though not all people with disability participate in the NDIS, that has raised a significant change in terms of standards that we expect of delivery of services, and also the role of a Quality and Safeguards Commission in ensuring that delivery of services meet particular standards.

To what extent would any review of the accreditation standards take into account those broader changes in the delivery of services to people with disability in the community?

MS WALTERS:  At the moment, the AMC is going through its initial, I suppose, scoping work on the review of the Standards which is precisely looking at these issues, what has changed in health services and requirements since the last review, and what should be reflected in the revised Standards.

MS EASTMAN:  Can I pause on the Standards and come back to Professor Murray and Professor Haq.

In terms of the flexibility you have in curriculum development at the university level,  
what has changed, if anything, to respond to the changes brought about by the NDIS and the delivery of disability services in Australia?  Has there been any specific changes to the way in which you have developed the curricula?

MS WALTERS:  So the Accreditation Standards have not changed in that period, but what I have observed --- in preparation for this hearing, I have looked at the accreditation submissions made by medical schools, and not systematically but by looking at, say, four to five submissions to the AMC.  What I can observe is a focus in medical schools, particularly in the last 18 months, where they are talking about the sorts of changes that the University of Sydney is making, and talking about changes in expectations about longitudinal placements for students, a broadening, if you like, of clinical placements and experience.

So even though it is not in the Standards, what we see is medical schools are making their own changes which fit within the standards.

MS EASTMAN:  Professor Murray, Professor Haq, do you want to comment on those issues at all?

Professor Murray first?

PROFESSOR MURRAY:  Thank you very much.  I absolutely agree, and it has been a long push, really, for moving the context of learning, and in particular the phase of medical education that is spent under supervision in a real world environment dealing with individuals, families.  From the big teaching hospital it was the tradition, I suppose, where I mostly trained, although we did have --- 35 odd years ago we did have community experience, but there is a lot more of that now, so that has been a very deliberate move.

I think, as well, in the   so in some ways it has paralleled the developments of NDIS, a greater emphasis upon medicine in the community as opposed to in the hospital.  A greater emphasis upon function, dignity and family rather than sickness and treatment in the hospital.  So those have been all very deliberate and sort of long running trends in medical education.

I think I will come back to the question of placement, if I might, because I think it is a really fundamental opportunity perhaps that the Royal Commission may consider.

I might just go back to the AMC process.  I think some of the value of the AMC is not whether or not a checklist on whether one is deemed to have met the minimum standards of accreditation as set out.  I think in some ways that is the least valuable aspect of their education process, but I have been around the world advocating for these things, is that the culture is very much about continuous enhancement or continuous improvement, so those of us who participate either as the one being accredited or on the accreditation panels that would include community people, are very active in sharing and disseminating ideas in a community practice, and I think that has been a very valuable aspect of the work of the AMC.  It is in fact not a  
checklist auditor but a facilitator of best work practice, which I think is a great strength.

MS EASTMAN:  Professor Haq?  I think the word of COVID 19: you are on mute.

PROFESSOR HAQ:  Yes, I know, terrible.

I concur with Professor Murray, certainly in the medical program, with our revised program that I was involved in developing, have become more focused on community placement activity, precisely for the reasons that Professor Murray said, and most people do not spend their lives in hospital.  They spent their lives out of hospital in their actual daily lives, how do our students access those placements opportunities and lived experience opportunities, with a range of healthcare providers, that is what we are engaging in Year Two.  Particularly one of the strengths in Sydney that my role is, is interprofessional education.  Patients with intellectual or cognitive disabilities are not just looked after by a doctor or nurse, but it's multi disciplinary teams, and something we are really looking forward to developing is actually getting our students together in any particular different context, but this would be another excellent on how to best care for a patient and their family care or support workers with an intellectual or cognitive disability, so I think that is where we are moving, and NDS fits in to that sort of broad area too.

MS EASTMAN:  The Royal Commission has heard a lot about the importance of multi disciplinary teams, particularly in the Royal Commission   and the Commissioners have not produced a report yet, but they have heard evidence in relation to the prescribing of psychotropic drugs that challenging behaviours on behaviours of concern, sometimes it is the doctor, and usually a GP or a paediatrician, who will be that first port of call as to whether the prescription is going down a behaviour management pass, or a health path.  And the importance of a multi disciplinary approach has been raised there, how do you meet the Accreditation Standards in bringing in that multi disciplinary approach, and do the Accreditation Standards need to be more open to incorporating multi disciplinary approaches, particularly for people with cognitive disability?

PROFESSOR HAQ:  I think I probably concur, there is going to be work in the revised AMC standards on interprofessional and multi disciplinary learning, I think that is going to be really important, it is really important now, even more so for our health professionals of the future.  We at Sydney have developed a framework from entry to exit for interprofessional capabilities, is what we've called them, working with other students and learning from them in classroom environments, simulated environments, and then the real clinical environments under supervision.  That covers a variety of contexts, multi disciplinary team meetings, managing conflict and so on and so forth.  But I could see a vulnerable population would also fit into an area where we could teach and learn in a multi disciplinary context, yes.

MS EASTMAN:  Ms Walters, I see you have just disappeared off the screen.  I hope you have not left us?
 

Apologies.  I thought normally it is hard for a witness to escape but maybe on the Zoom it is a bit easier.  Can I ask you this   there is absolutely nothing in either the national law or the policies for developing accreditation standards that would prevent there being a specific accreditation standard directed to the care and treatment of people with cognitive disability?  There is nothing preventing that going into the Standard, is there?

MS WALTERS:  No, there is nothing.

MS EASTMAN:  And the reservation as to including a specific standard concerning people with cognitive disability is really here a floodgates, that if we have cognitive disability in, then we will have to have all of these other vulnerable characteristics added as well, am I reading the evidence correctly, that that seems to be a concern about being overly prescriptive in it guying a particular population?

MS WALTERS:  Yes, that is certainly the expressed concern.  I think it is fair to say that in the current review of the accreditation standards, the structure of the standards is one of the issues that we will be looking at, because clearly, the way the Standards are structured now probably make the curriculum and the content of the curriculum, I suppose, a smallish part of the eight standards even though it is an incredibly important part.

One of the things we are looking at is how might we structure the standards, so themes and issues that arise, curriculum themes, issues about including particular sections of the community or particular patient groups within curriculum design, if you like, or in teaching, is one of the topics that we are currently discussing.

So it is possible to change it.

MS EASTMAN:  And you have gone down this path in the past in relation to specific identification of Aboriginal and Torres Strait Islander and Maori population, and picking up the New Zealand concept of cultural competency, or --- and I think New Zealand has recently revised this to describe it as cultural safety.  That is a model which we have heard does put pressure on a crowded curriculum, but as I understand the evidence given to the Royal Commission this morning, even though that has created challenges for universities, it has been possible to incorporate within the curriculum.

Should it be a question about how much more space there is in a curriculum, or should it really be about curriculum design to incorporate some of these particular areas such as First Nations people or, may I add, people with cognitive disability?  Can that be done?

MS WALTERS:  It - certainly the accreditation standards can certainly be structured in a different way that would give focus and attention to other curriculum topics and other populations.  I guess it is the issue of whether there is agreement that that  
should be the way it’s done.  But the issue about curriculum overcrowding, I think, would best be answered by Dr Haq or Professor Murray.

MS EASTMAN:  Commissioners, in the time that is available, I want to ask the members of the panel whether they have read the proposition document we circulated earlier, and I can ask you Professor Murray, can I start with you   do the Medical Deans have any violent objections to any of the propositions that we have circulated?

CHAIR:  Is that different from an objection?

MS EASTMAN:  I qualify it by "violent" objection.

CHAIR:  You can ignore the word "violent".

PROFESSOR MURRAY:  I quite like "violent agreement".  I am in violent agreement as to the objective that we produce medical graduates who are able to understand in a very authentic way the lived experience and perspective of individuals and families living with intellectual disabilities.  So I'm completely on board with that - violent agreement there.

So where we differ is the means to the end.  I absolutely get that the general public and many would say, well just put it in the curriculum.  And that can join a very long list I can tell you, because we get letters every other week, "We need more of this in the curriculum".

From all sorts of patient groups, we get gender issues, be it particular age or ethnic group, refugees, particular disease groups, whatever it might be, there is a multitude of completely legitimate interests in particularity.

What is underpinning all or many of those, however, are more fundamental things about the skills and attitudes of medical practitioners when it comes to the ability of some of the fundamentals, such as accurate, empathetic, person centred communication, being an example we touched on earlier, and I think we would try to put a much greater emphasis on that.  I think there is room for developing some higher quality learning resources that are updated and readily accessed.

So for instance, in our own curriculum, again we have a six year curriculum so we have a bit more headroom and it is a bit unusual, but we have a entire week on disability, including individual patients, of individual people attending with particular sorts of lived experience, and indeed a video exercise analysing and reflecting upon the experience of a mother and daughter with an intellectual disability so there is quite a lot of good practices (audio distorted) I think they provide a high quality learning resource in the style of NDIS that are readily accessed by very receptive community access, which would appreciate the availability of such things to use and/or adapt.  I think that would be an impactful thing to do.
 

But the other thing I must say, if we are coming to time, one of the biggest reforms I would really invite the Commission to consider, and that is not a feature of the circumstance at the moment, is the question of supervised quality placements.  It is a fact of history that the way in which medical schools and clinical placements are funded, is that most of those resources are tied up in public hospitals --- that is the way in which the funding system works, there is a requirement that public hospitals under the national reform agreements and their predecessors provide clinical teaching and supervision opportunities for medical students, but that then limits it to the hospital setting.

We have, in more recent times, had the opportunity for there to be payments to general practitioners to have medical students placed in community general practice, and so have a formal paid teaching role for students in community general practice.  But as far as other agencies, and particularly community agencies and those managing and supporting people and families living with intellectual or cognitive disability, there is no mechanism for remuneration or support for that environment, and indeed with the development of NDIS, the whole question of there being a sort of parallel investment in the health profession, medical and other health professional placement in the community support services around NDIS, it simply does not exist.  It has not yet been developed yet.

I believe that is a major gap.  I think Proposition 7, if I recall, goes to that, and I would really like to underscore that.  I think that is a very important opportunity for the Commission to contemplate.

But beyond that, as far as means and ends, I agree with the end.  As a specific means, detailed, highly atomised prescriptive curriculum and standards in a very literal sense --- I'm not talking syllabus but curriculum --- I think would not be a sensible way to achieve the end.  But I'm completely on board with the end. 

CHAIR:  Wouldn't that be a false dichotomy?  There are various ways in which you can achieve the end.  The starting point has to be, I would have thought, whether there is something particularly significant about the position of people with cognitive disability and the way in which the medical profession interacts with those people.  If there is, then it may be entirely a matter for medical schools and for judgement as to how the necessary skills, empathy, understanding, and so on, skills are communicated.  Not necessarily by a prescriptive separate subject, or anything like that.

I expect the description may be in the discussion which has occurred.  And I may be misunderstanding it, but for you, Professor Murray and for you Professor Haq, you seem to think a pedagogical approach that leaves the students having more sympathy, capacity to communicate is transferrable among different vulnerable populations, and I wonder about that.

I wonder if there are not things specific to particular populations. From what we have  
heard in this Royal Commission, and in a number of hearings, the issues that arise for people with cognitive disability do not seem to have ready counterparts in other vulnerable populations.  They may have other issues, and there may be some overlay, but I just wonder whether your approach may not be a little too generic, if I may put it that way.

PROFESSOR HAQ:  I think that is probably starting from where I was coming from.  I think that under an umbrella of vulnerable populations, of which there are many with many different needs, I think we need to teach our students in nuanced ways what the needs of particular groups are that are completely different, I agree.  But again these are students who are going to graduate.  This is part of the learning continuum.  They do not learn everything at point of graduation.  There is another 20 to 30 years for them to keep on learning.

Our job is to give them a platform and a foundation for where they are going to go in the future.  So there are general capabilities, absolutely right.  But there are also specific capabilities for disabilities of different kinds and other vulnerable types of groups that we should be ensuring our students have the capacity to recognise.  I think that is really, really important.  And then work out which bits of those skills armoury, they need for which particular time for whichever group of patients or community they are dealing with, and also how to work effectively in a team for the benefit of that patient.  I think also really important is to recognise poor practice they may well see in a health environment all over the country, and how then to call that out.  That is the really important.  I think our students really want to be able to do that, but do not feel empowered to.  And that is something we really need to work on.

So absolutely, Senior Counsel.  I think it is not about saying generic capabilities will solve everything, but giving a foundation and applying that foundation in specific circumstances, and seeing what nuances are needed.

MS EASTMAN:  Ms Walters, any view about the propositions or any, as I said, violent disagreement with those propositions?

MS WALTERS:  I wanted to tease out the competency framework, if I could.  I think we see lots of documents written as competency frameworks, which I think variously are taken up by medical schools, and in different ways.  But I think there is actually value in the development of the competency framework.  Because it is the thing about, the discussion about what are key skills and core competencies, and the engagement with the stakeholders to develop the document and to think about what does this mean.  I think there is real learning in that.  If I think, for example, the Indigenous health competency framework, I think there was as much value in the actual development of the document, and then the development of the resources that are available for medical schools to apply to their course.  I think that is a really valuable exercise.  I think there is material already available in Australia that could form the basis of that.  The work done by New South Wales Health in the development of its mental health capabilities for people with intellectual disability is a great start as a competency framework.
 

In relation to the accreditation standards, I suppose it is how the standards are changed that is the important issue.  I guess we, in terms of the AMC's thinking about this, we are at very early stages in thinking about the scope of change to the standards, but it is certainly an issue that we will pick up in this review and will consult on widely early in 2021.

MS EASTMAN:  Dr Haq, did you want to add something?

PROFESSOR HAQ:  Again, working together as a team rather than each university or jurisdiction working independently, if we could agree some capabilities.  For me that is a great word.  What do we want our students to be able to do on graduation in a group, in the vulnerable patient group as a whole but within specific areas in intellectual disability and cognitive disability.  I think that would help.  It would prevent each university having to do their own thing and create their own, and allow us as a community of practice to develop resources, or use existing resources, that we could then map onto that.

MS EASTMAN:  Professor Murray, that proposal that Professor Haq has just described seems to be perfectly placed in the work of the Medical Deans.  Would you agree?

PROFESSOR MURRAY:  Yes, I do.  Having a competency framework, and set of commonly share learning resources around that, and being able to put that through.  For instance, our Medical Education Collaboration Committee, which is a specific committee of practice of which Professor Haq is an active participant, is precisely the right way to have this.  Because every curriculum, sequencing, structure --- the way in which particular case examples, for instance, in a problem based curriculum will vary.  But being able to draw upon a common resource set and a set of understanding of what good practice looks like I think helps to facilitate (inaudible).

MS EASTMAN:  Dr Palipana, can I give you the final say as a recent medical graduate, what are your views on the propositions, and any final perspectives as a person with lived experience of disability, but also serving on the front line, so to speak?

DR PALIPANA:  I have no violent objections to the proposition.  But I think medical education is a complex continuum with a lot of stakeholders.  So the medical schools graduate doctors, and then subsequently the specialist training colleges that will have them on.  I think each speciality has its own subtleties of how to deal with people with disabilities.  For example, how does an anaesthesiologist best deal with a patient with a cognitive disability?  How does a psychiatrist, how does a surgeon?  But in between graduating medical school and undertaking a training program there is a large cohort of doctors that do a lot of front facing work, in the emergency departments, clinics, in and around hospitals.  And there are thousands of them across Australia.  And they will be there from the graduating year to five, six, seven, eight years sometimes before they start speciality training.
 

So I think it is really important that that big group of doctors are best equipped to care for people with disabilities, because they may sometimes be the only doctor that a person with a disability sees, and they may not have any other senior input in extreme circumstances.

So I do think it is important that we prepare people to best care for people with cognitive impairments.  I do agree there is a huge gap and risk with people with cognitive disabilities and other disabilities that we need to do better as a profession to care for.

MS EASTMAN:  Can I thank you all.  You have put an enormous amount of time and care into the preparation of the material for this hearing of the Royal Commission.  We are indebted to all of you.  Commissioners, that concludes the questions I wish to ask the panel members.

CHAIR:  Thank you, Ms Eastman.  I will ask my colleagues if they have any questions?  Commissioner Atkinson?

COMMISSIONER ATKINSON:  I do have a lot, but I think the time has come to finish with a word.  Thank you.

CHAIR:  Commissioner Bennett?

COMMISSIONER BENNETT:  No, thank you.

CHAIR:  May I endorse the comments of Ms Eastman.  We are very grateful for each of you for the evidence you have given and for the considerable thought and effort that has gone into the preparation of the documentary material that you have provided.  It has, again, been an extremely interesting, informative and suggestive discussion, and we have I think some very valuable ideas to go on with.  So thank you very much for your contributions.

PROFESSOR HAQ:  Thank you.

DR PALIPANA:  Thank you.

PROFESSOR MURRAY:  Thank you.

THE WITNESSES WITHDREW

MS EASTMAN:  Commissioners, that concludes the proceedings for today.  I would ask you to adjourn, and resume tomorrow at 10.00am.

CHAIR:  We will do that.  We will resume at 10.00am tomorrow Sydney time.   
Thank you.

ADJOURNED AT 4.14 PM (ADST) UNTIL WEDNESDAY, 16 DECEMBER 2020 AT 10.00 AM (ADST)