Australian Public Health Service Research Articles

Mental Health Workforce Knowledge about LGBTIQ Identities and Related Responsiveness: A Mixed Methods Approach

Abstract LGBTIQ people are at greater risk of mental health challenges, compared to the general population, and are overrepresented in mental health services. Past research has sought to understand how mental health workforce rate their knowledge to meet the needs of LGBTIQ consumers. However, this past research has largely aggregated the LGBTIQ identities, despite evidence that rates of mental health challenges vary within the LGBTIQ community. Using semi-structured interviews, this study sought to explore how seven mental health staff members from an Australian public health service rated and described their knowledge to responsively meet the needs of the different LGBTIQ identities. While participants tended to rate and describe themselves as having some knowledge about most of the LGBTIQ identities, there was a divide between sexual orientation, gender identities and intersex variations, with the former typically being rated and described as being better understood. This is the first known study to place central focus on disaggregating the LGBTIQ identities in mental health research and provides initial insights into how mental health workforce rate and describe their knowledge for nuanced and responsive practice.

Evaluation of research capacity and culture of hospital pharmacists and pharmacy technicians in a state-wide Australian public health service: A cross-sectional survey.

Integrating research with clinical practice is essential for evidence-based practice and continuous improvement in health care. Little is known about the research capacity and culture of the Australian hospital pharmacy workforce, particularly in rural areas and for pharmacy assistants/technicians. This paper aims to characterise the research capacity and culture of a state-wide public-hospital pharmacy service at organisation, team and individual levels, and to explore variables which influence research confidence and success. An online, anonymous, cross-sectional survey using the validated Research Capacity in Context tool was emailed to all pharmacists, pharmacy assistants/technicians and non-clinical staff employed by a statewide pharmacy service in South Australia. Respondent characteristics and organisation, team and individual scores of research skill/success were summarised using descriptive statistics. T-tests compared results for pharmacists and pharmacy assistants/technicians and metropolitan-based and non-metropolitan-based staff. Regression analyses explored predictors of pharmacists individual research skill/success scores. A response rate of 43.4% (n=278/641, 19 sites) was obtained. Respondents were primarily pharmacists (68%) and pharmacy assistants/technicians (28%); 91% were practicing in a metropolitan setting. 47% reported no research experience. Highest scores for research skill/success were observed at the organisational level (mean score 6.0/10) vs. team (mean score 5.6/10) and individual levels (mean score 5.1/10). Within each level specific items that scored poorly were identified. Individual research skills/success scores were higher in pharmacists vs. pharmacy assistants/technicians (mean score 5.2/10 vs. 4.2/10, p<0.01), and were not different between staff in metropolitan vs. non-metropolitan settings (mean scores 5.2 vs. 5.0, p=0.77). For pharmacists, undertaking undergraduate or internship research projects or postgraduate research training were associated with higher individual scores of research skills and success. This research extends understanding of hospital pharmacy research capacity and culture, describes research skills and success in hospital pharmacy technicians/assistants for the first time and highlights low-scoring areas; these could be targeted to improve research capacity and culture at an individual, team and organisational levels.

Early career psychologists “muddling through the same challenges”: how the experience of structured group supervision can support the transition to work

ABSTRACT Objective The transition from postgraduate psychology student to health professional is associated with steep learning and is under-researched. This qualitative study aimed to understand the experience of newly graduated psychologists and evaluate whether participation in a group supervision program offered within an Australian public health service assisted in the transition to work. Method All psychology graduates attending the group supervision program were invited to participate in a focus group. All responses were audio-recorded, transcribed and de-identified. Two focus groups were held with psychology graduates (n = 7) and one focus group was held separately with the psychology primary supervisors (n = 4). Results Thematic analysis generated five key themes: developing proficiency in core competencies, meeting psychology registrar requirements, meeting professional development needs through supervision, connecting with peers and feeling valued by the organisation. Conclusions While the experience of psychology graduates can be stressful and isolating, the group program provided peer connections, normalised transition to work experiences and provided a supportive platform for acquiring new knowledge and skills. The provision of a structured and competency-based group supervision program has benefits of meeting the developmental needs of psychology graduates professionally and helps them feel valued and supported by their workplace. KEY POINTS What is already known about this topic: New graduates in psychology are an expanding and important workforce in Australian health services. The transition from postgraduate degree to practicing psychologist is associated with steep learning and can be stressful at times. Group supervision is available in training and workplaces but is often inconsistent and its benefits are under-researched for recent psychology graduates. What this topic adds: (1) The provision of a structured and competency-based group supervision program for early career psychologists has the potential to meet the professional needs of these psychologists and help them feel supported and connected to their peers. (2) Structured group supervision programs offered in the workplace help normalise the psychology registrars experience and help them feel valued by their workplace, potentially impacting workforce retention. (3) A model is proposed for providing professional development and support in new psychology graduates that may be applied to other health services in Australia.

Promoting mental health recovery by design: Physical, procedural, and relational security in the context of the mental health built environment.

The rates of mental health hospitalisations in Australia are rising. This paper presents the findings of a study undertaken in a regional mental health unit. The aim of the study was to obtain user perspectives to inform the redesign of the unit, which provides inpatient mental health services to rural and regional adults. A qualitative descriptive study with data collected via focus groups and in-depth interviews was undertaken with 38 participants, including current inpatients, carers and 27 staff members of a single regional inpatient mental health unit. The 25-bed mental health inpatient unit accommodates adults from 18+ years of age. The mental health unit sits within a referral hospital precinct and is associated with community-based mental health services within a large regional and rural Australian public health service. The analysis of interviews and focus groups with patients, carers and mental health professionals revealed three major themes congruent with the literature These were: Firstly, Theme 1: Rooms should be designed to promote physical security. Next, Theme 2: Purposeful planning to support interactions between users and systems will promote relational security. And finally, Theme 3: Optimizing service integrity should promote procedural security. Based on the themes arising from the study, a list of recommendations was produced to inform the design of a new build for a regional mental health unit. In particular, all users of the space should expect that the built environment will promote their physical security and psychological safety and accommodate a wide range of diversity and acuity. The aesthetics should align with the promotion of recovery in the context of person-centred and trauma-informed models of care. Designers should plan to alleviate boredom and accommodate meaningful wayfinding. Mental health nurses should have spaces that support their work without compromising their relational security with consumers. Building designers should optimize therapeutic environments to facilitate dignified intensive and stabilizing treatments and eliminate vicarious stigma associated with caring for people with mental illness. This study provides valuable insights from a community of users who have experienced receiving and delivering mental health care within a regional and rural mental health unit.

A qualitative study of hospital clinical staff perceptions of their interactions with healthcare middle managers

PurposeThe authors explored clinical staff perceptions of their interactions with middle management and their experiences of the uncongeniality of their working environment.Design/methodology/approachSemi-structured interviews of clinical staff from an Australian public health service's Emergency, Surgery and Psychiatry departments. Volunteer interview transcripts were inductively coded using a reflexive thematic content analysis.FindingsOf 73 interviews, 66 participants discussed their interactions with management. Most clinicians considered their interactions with middle management to be negative based on a violation of their expectations of support in the workplace. Collectively, these interactions formed the basis of clinical staff perceptions of management's lack of capacity and fit for the needs of staff to perform their roles.Practical implicationsStrategies to improve management's fit with clinicians' needs may be beneficial for reducing uncongenial workplaces for healthcare staff and enhanced patient care.Originality/valueThis article is among the few papers that discuss interactions with management from the perspective of clinical staff in healthcare. How these perspectives inform the perception of workplace uncongeniality for clinicians contributes greater understanding of the factors contributing to adversarial relationships between clinicians and managers.

Barriers and Motivations to Integrating Environmental Performance in the BSC: a case study in health care

PurposeThis study aims to explore the barriers and motivations to integrating environmental performance into balanced scorecards (BSCs).Design/methodology/approachThis research adopted a qualitative case study approach with semi-structured interviews within an Australian public health service organisation. Secondary document analysis was performed using annual reports, strategic plans and website data.FindingsThe internal barriers creating resistance to incorporating environmental performance dimensions into the BSC include the existing role of environmental disclosure, insufficient sustainability BSC knowledge, lack of BSC champion support, organisational culture and limited environmental commitment practices. Solutions revealed to support decisions to integrate environmental performance in the BSC include recruiting sustainability expertise, articulating financial motivations and recognising external pressures.Practical implicationsThe findings provide suggested actions for other organisations facing similar challenges regarding integrating environmental performance into a BSC.Social implicationsIn the current business environment, organisations face growing pressure to consider environmental performance in their BSCs. This study provides insights into the potential problems that prevent or delay the integration of environmental issues into BSCs.Originality/valueThis study provides evidence on how institutional and external factors influence barriers and motivations to embed environmental performance measures into a BSC. This study demonstrates how health-care organisations can effectively overcome barriers by modifying specific institutional artefacts. This is an important contribution to the body of knowledge because there is limited empirical research regarding integrating environmental issues into a public sector BSC that projects key organisational commitment indicators.

Perceptions of clinical leaders and managers of inpatients with obesity in an Australian public health service

Perceptions of clinical leaders and managers of inpatients with obesity in an Australian public health service

Case study of a stepped-care psychological service for healthcare professionals working in critical care.

Psychological injury is common among healthcare professionals and is expected to be further exacerbated by the current global pandemic, with the far-reaching impacts of this workplace trauma yet to be fully realised. Our Intensive Care Unit and Emergency Department sought to proactively introduce strategies that might reduce the anticipated short- and longer-term negative impact of the pandemic on staff and ultimately patients and families. Our organisation facilitated the temporary redeployment of senior psychologists to provide staff-focused support. Interventions included leader targeted training to increase the skills in this group, specifically for this situation, and site visits to allow for staff to meet with psychologists. Staff experiences of the intervention were explored through the direct observations of the psychologists leading the approach maintained through contemporaneous activity tracking records. An internal and embedded staff psychological service fosters help-seeking behaviours and is considered a desirable and acceptable model for healthcare leaders and professionals. What is known about the topic? Healthcare professionals are at increased risk of psychological distress and injury caused by the inherent stress of their role. What does this paper add? This paper provides service providers with insights into the benefits of an embedded staff psychological service to support the psychological wellbeing of healthcare professionals and teams within an Australian public health service context. What are the implications for practitioners? An embedded staff psychological service can better meet the psychological needs of healthcare professionals and teams by focusing on prevention and early intervention strategies through targeted and tailored systems, teams, and individual interventions.

Context Matters: Findings from a Qualitative Study Exploring Service and Place Factors Influencing the Recruitment and Retention of Allied Health Professionals in Rural Australian Public Health Services.

Chronic health workforce shortages significantly contribute to unmet health care needs in rural and remote communities. Of particular and growing concern are shortages of allied health professionals (AHPs). This study explored the contextual factors impacting the recruitment and retention of AHPs in rural Australia. A qualitative approach using a constructivist-interpretivist methodology was taken. Semi-structured interviews (n = 74) with executive staff, allied health (AH) managers and newly recruited AHPs working in two rural public health services in Victoria, Australia were conducted. Data was coded and categorised inductively and analysed thematically. The findings suggest that to support a stable and sustainable AH workforce, rural public sector health services need to be more efficient, strategic and visionary. This means ensuring that policies and procedures are equitable and accessible, processes are effective, and action is taken to develop local programs, opportunities and supports that allow AH staff to thrive and grow in place at all grade levels and life stages. This study reinforces the need for a whole-of-community approach to effectively support individual AH workers and their family members in adjusting to a new place and developing a sense of belonging in place. The recommendations arising from this study are likely to have utility for other high-income countries, particularly in guiding AH recruitment and retention strategies in rural public sector health services. Recommendations relating to community/place will likely benefit broader rural health workforce initiatives.

Suicidal Presentations to Emergency Departments in a Large Australian Public Health Service over 10 Years.

This paper presents trends and characteristics for 32,094 suicidal presentations to two Emergency Departments (EDs) in a large health service in Australia across a 10-year period (2009–2018). Prevalence of annual suicidal presentations and for selected groups of consumers (by sex, age groups, and ethnicity) was determined from a machine learning diagnostic algorithm developed for this purpose and a Bayesian estimation approach. A linear increase in the number of suicidal presentations over 10 years was observed, which was 2.8-times higher than the increase noted in all ED presentations and 6.1-times higher than the increase in the population size. Females had higher presentation rates than males, particularly among younger age groups. The highest rates of presentations were by persons aged 15–24. Overseas-born persons had around half the rates of suicidal presentations than Australian-born persons, and Indigenous persons had 2.9-times higher rates than non-Indigenous persons. Of all presenters, 70.6% presented once, but 5.7% had five or more presentations. Seasonal distribution of presentations showed a peak at the end of spring and a decline in winter months. These findings can inform the allocation of health resources and guide the development of suicide prevention strategies for people presenting to hospitals in suicidal crisis.

Australian Junior Doctors' Perspectives on Psychiatry Teaching in Medical School.

This research aimed to investigate the perspectives of junior doctors regarding the psychiatry teaching they received in medical school and to ascertain which areas of psychiatry are relevant to practicing junior doctors. In 2017 an online survey was sent to junior doctors affiliated with an Australian public health service. Respondents were asked to rate the degree of preparation their medical school education had provided, in regard to the application of psychiatry knowledge/skills in their practice. Respondents were also asked to specify which psychiatry knowledge/skills were relevant to their practice and how psychiatry teaching in medical school could be improved. Authors generated descriptive statistics for the quantitative data and reviewed the open-ended question data to form themes, guided by the general inductive approach. The responses of 82 junior doctors were included in the analysis. Over half of the respondents believed that their psychiatry teaching in medical school had prepared them well for their current clinical practice. Responses to open-ended questions noted the following areas of psychiatry as most relevant to practice: delirium, mood disorders, risk assessment, and de-escalation. Respondents emphasized the importance of teaching psychiatry knowledge/skills relevant to the management of patients seen outside of psychiatric units. Psychiatry teaching in medical school appears to be providing adequate preparation for most junior doctors. However, there is still significant room for improvement. Changes to the curriculum should be considered, with a greater emphasis on clinically relevant psychiatry knowledge/skills, increased active learning sessions, and a broader range of clinical placements.

Oxycodone prescribing in the emergency department during the opioid crisis.

Misuse of prescription opioids is a significant public health issue in Australia. There has been a rapid rise in prescription opioid use, with an associated increase in overdose and death. The over-prescribing of oral opioids, especially oxycodone, in the ED has been identified as a contributor to this problem overseas. It is unclear if similar practice occurs in the Australian ED. The primary aim of our study was to identify the incidence of oral oxycodone administration to patients within the ED. The secondary outcome was to identify the incidence of oxycodone prescribed to patients on discharge from the ED into the community. Our study was designed as an observational, retrospective data analysis of the incidence of oxycodone prescribed within the three EDs of a large Australian public health service. All immediate-release (IR) and slow-release (SR) oral oxycodone prescribed over a 4-year period (2015-2018) was included. There were 890 557 presentations to the three EDs during the period, which resulted in 288 242 episodes of oxycodone administration within department, equivalent to 324 administrations per 1000 presentations. There were 39 381 prescriptions for oxycodone provided on discharge, resulting in an incidence of 44 prescriptions per 1000 discharged. The most frequently prescribed opioid medication in the ED was oxycodone IR 5 mg, 78.6% of discharge prescriptions generated provided a maximum quantity (20 for IR formulation or 28 for SR) of tablets allowable under the pharmaceutical benefits scheme. There is a higher incidence of oxycodone prescribing in the Australian ED than previously recognised. An overuse of oxycodone may be contributing to adverse patient outcomes and a public health crisis. Hospitals should consider appropriate steps to reduce the incidence of opioid prescribing and the supply of these medications into the community.

Hospital Staff Report It Is Not Burnout, but a Normal Stress Reaction to an Uncongenial Work Environment: Findings from a Qualitative Study.

(1) Background: The issue of burnout in healthcare staff is frequently discussed in relation to occupational health. In this paper, we report healthcare staff experiences of stress and burnout. (2) Methods: In total, 72 healthcare staff were interviewed from psychiatry, surgery, and emergency departments at an Australian public health service. The sample included doctors, nurses, allied health professionals, administrators, and front-line managers. Interview transcripts were thematically analyzed, with participant experiences interpreted against descriptors of burnout in Maslach’s Burnout Inventory and the International Statistical Classification of Diseases and Related Health Problems (ICD-11). (3) Results: Staff experiences closely matched the ICD-11 description of stress associated with working in an uncongenial workplace, with few reported experiences which matched the ICD-11 descriptors of burnout. (4) Conclusion: Uncongenial workplaces in public health services contribute to healthcare staff stress. While previous approaches have focused on biomedical assistance for individuals, our findings suggest that occupational health approaches to addressing health care staff stress need greater focus on the workplace as a social determinant of health. This finding is significant as organizational remedies to uncongenial stress are quite different from remedies to burnout.

An explanation of turnover intention among early-career nursing and allied health professionals working in rural and remote Australia - findings from a grounded theory study.

Rural health workforce shortages are a global phenomenon. Countries like Australia, with industrialised economies, large land masses and broadly dispersed populations, face unique rural health challenges in providing adequate services and addressing workforce shortages. This article focuses on retention of early-career nursing and allied health professionals working in rural and remote Australia. Some of Australia's most severe and protracted rural workforce shortages, particularly among early-career health professionals, are in public sector community mental health (CMH), a multidisciplinary workforce staffed primarily by nurses and allied health professionals. This study investigated how employment and rural-living factors impacted the turnover intention of early-career, rural-based CMH professionals in their first few years of working. A constructivist grounded theory methodological approach, primarily guided by the work of Charmaz, was selected for the study. By implication, the choice of a grounded theory approach meant that the research question would be answered through the development of a substantive theory. Twenty-six nursing and allied health professionals working in CMH in rural New South Wales (NSW) for the state health department services participated in in-depth, semi-structured interviews. The study sought to identify the particular life factors - workplace conditions, career-advancement opportunities and social and personal determinants - affecting workers' turnover intention. The substantive grounded theory was developed from an identified core category and basic social process. The turnover intention theory provides a whole-of-person explanation of turnover intention. It was developed based on an identified core category of professional and personal expectations being met and an identified basic social process of adjusting to change. The theory posits that an individual's decision to stay or leave their job is determined by the meeting of life aspirations, and this relates to the extent of the gap between individuals' professional and personal expectations and the reality of their current employment and rural-living experience. The extent of individuals' professional and personal expectations can be measured by their satisfaction levels. A major finding from the identification of the basic social process was that, in the adjustment stages (initial and continuing), turnover intention was most strongly affected by professional experiences, in particular those relating to the job role, workplace relationships and level of access to continuing professional development. In this stage, personal satisfaction mostly concerned those with limited social connections in the town (ie non-local - newcomers). Having reached the 'having adapted' stage, the major influence on turnover intention shifted to personal satisfaction, and this was strongly impacted by individuals' life stage. By drawing on the turnover intention theory and the basic social process, it is possible to make a risk assessment of individuals' turnover intention. Three levels of risk were identified: highly vulnerable, moderately vulnerable and not very vulnerable. The study offers a holistic explanation of life factors influencing the turnover intention of early-career health professionals working in public health services in rural NSW. These findings and the turnover intention risk matrix are thought to be suitable for use by Australian public health services and governments, as well as in other highly industrialised countries, to assist in the development of policies and strategies tailored for individual health professionals' work-experience level and life stage. By adopting such a whole-of-person approach, health services and governments will be better positioned to address the life aspirations of rural-based, early-career health professionals and this is likely to assist in the reduction of avoidable turnover.

The development and practical application of a simulation model to inform musculoskeletal service delivery in an Australian public health service

Timely access to orthopaedic and neurosurgery services in public hospitals is difficult to achieve due to constrained resources and rising demand with the result that waiting time targets are often not met. Advanced physiotherapy-led clinics can assist in managing demand by directly assessing and managing many patients without the need for consultation with a medical specialist. The purpose of this study was to develop and apply simulation modelling to determine the scale and mix of services required to efficiently manage demand from patients with musculoskeletal conditions in one health district. DesignWe designed a simulation model to estimate service demand over five years and test different service configurations (medical specialist-led or advanced physiotherapy-led) to meet waiting time targets and reduce waiting lists in orthopaedic and neurosurgery services. ResultsWithout intervention, the combined orthopaedic and neurosurgical outpatient waiting list is predicted to grow from 11,000 to over 15,000 patients over a five year period. To achieve waiting time targets within 2 years the scale of services would need to approximately double and the most efficient combination would be to direct approximately 50% of referrals to medical specialist clinics and 50% to advanced physiotherapy-led clinics. ConclusionsIn the health system modelled, a significant gap was identified between future demand and current provision of services. Simulation modelling was able to assist service planners understand the demand and identify effective management strategies.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study.

The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service. There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice. This study used a sequential exploratory design with data collected in 2014. A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation. Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need. Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making. There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.

The Impact of Integrating Crisis Teams into Community Mental Health Services on Emergency Department and Inpatient Demand.

This investigation focused on the impact of integrating crisis team members into community mental health services on emergency department and adult mental health inpatient unit demand within an Australian public health service. Mixed methods were used including (a) the comparison of service use data with that of two other comparable services (both of which had community-based crisis teams), (b) surveys of (i) patients and carers and (ii) staff, and (c) focus groups with staff. The numbers of emergency department presentations with mental health conditions and adult mental health inpatient separations increased 13.9 and 5.7%, respectively, from FY2006/07 to FY2012/13. Between the three services, there were minimal differences in the percentages of presentations with mental health conditions, the distribution of mental health presentations across a 24-h period, and the triage categories assigned to these patients. Survey participants reported that patients used the emergency department due to the urgency of situations, perceptions that gaining access to mental health services would take less time, and the unavailability of mental health services when help is needed. Staff identified several issues (e.g. inappropriate referrals) that may be unnecessary in increasing emergency department demand. The integration of crisis team members into community mental health services does not seem to have produced an increase in emergency department admissions or inpatient separations beyond what might be expected from population growth. The potential may exist, however, to reduce emergency department admissions through addressing the issue of inappropriate referrals.

Effectiveness of clinical supervision of physiotherapists: a survey.

Limited literature exists on the practice of clinical supervision (CS) of professional physiotherapists despite current Australian safety and quality health standards stating that CS is to be provided to all physiotherapists. The aim of the present study was to evaluate the effectiveness of CS of physiotherapists working in an Australian public health service. CS was measured using the allied health-specific 26-item modified Manchester Clinical Supervision Scale (MCSS-26). Subscales of the MCSS-26 were summed for three domain scores (normative, restorative and formative) and a total score was calculated, which was compared with the reported threshold score of 73 for effective supervision. Sixty registered physiotherapists (response rate 92%), working for a large metropolitan public health service, with six different site locations, completed the survey. The mean (± s.d.) total MCSS-26 score was 71.0 ± 14.3 (95% confidence interval (CI) 67.4-74.6). Hospital site was the only variable that had a significant effect on total MCSS-26 score (P=0.005); there was no effect for supervisor or supervisee experience, or hospital setting (acute vs subacute). Physiotherapists scored a significantly lower mean percentage MCSS-26 score on the normative domain compared with the restorative domain (mean difference 7.8%; 95% CI 2.9-12.7; P=0.002) and the formative domain (mean difference 9.6%; 95% CI 6.3-13.0; P<0.001). Of the two subscales that form the normative domain, 'finding time' had a significantly lower mean percentage MCSS-26 score than 'importance/value of CS' (mean difference 35.4%; 95% CI 31.3-39.4; P<0.001). Within this publicly funded physiotherapy department there was uncertainty about the effectiveness of CS, with more than half the physiotherapists rating their supervision as less than effective, suggesting there is opportunity for improvement in the practice of physiotherapy CS. Physiotherapists scored lowest in the normative domain, indicating that they found it difficult to find time for CS.

An analysis of high-cost users at an Australian public health service organization

High-cost users generate extremely high costs when compared with average users in the same diagnostic-related group (DRG). They represent a major financial loss for a health service organization. The research was conducted using an area health service patient database for online analytical processing to produce descriptive statistics and graphs of 'high-cost' and 'non-high-cost users'. Trends and patterns were identified across key variables derived from clinical, financial and operational categories. The main results are: 20% of costs are spent by 3% of the population; elective admission is higher in the high-cost group; tracheostomy has the most number of cases and is the most expensive DRG; LOS is mostly longer for complex cases however, high costs can be attributed to other factors. In conclusion, these findings are potentially useful to patients, medical staff, management and health service decision-makers. The limitation of this study is the exclusion of profitability.

The national public health performance project: How do we know whether Australian public health services are performing?

Public health in Australia can boast success stories in many areas, including immunisation, tobacco control, cervical cancer screening, prevention of HIV–AIDS, and prevention of SIDS. However, these successes have not been translated into increased investment in the public health sector. Expenditure on preventive and promotional services, as a proportion of total health expenditure, has remained static over the last 30 years. There has been only a minor increase in the ‘community health’ category, a classification that includes some public health activities but also a range of personal care services.