Health System In Australia Research Articles

The value of a causal loop diagram in exploring the complex interplay of factors that influence health promotion in a multisectoral health system in Australia

BackgroundDespite calls for the application of complex systems science in empirical studies of health promotion, there are very few examples. The aim of this paper was to use a complex systems approach to examine the key factors that influenced health promotion (HP) policy and practice in a multisectoral health system in Australia.MethodsWithin a qualitative case study, a schema was developed that incorporated HP goals, actions and strategies with WHO building blocks (leadership and governance, financing, workforce, services and information). The case was a multisectoral health system bounded in terms of geographical and governance structures and a history of support for HP. A detailed analysis of 20 state government strategic documents and interviews with 53 stakeholders from multiple sectors were completed. Based upon key findings and dominants themes, causal pathways and feedback loops were established. Finally, a causal loop diagram was created to visualise the complex array of feedback loops in the multisectoral health system that influenced HP policy and practice.ResultsThe complexity of the multisectoral health system was clearly illustrated by the numerous feedback mechanisms that influenced HP policy and practice. The majority of feedback mechanisms in the causal loop diagram were vicious cycles that inhibited HP policy and practice, which need to be disrupted or changed for HP to thrive. There were some virtuous cycles that facilitated HP, which could be amplified to strengthen HP policy and practice. Leadership and governance at federal–state–local government levels figured prominently and this building block was interdependently linked to all others.ConclusionCreating a causal loop diagram enabled visualisation of the emergent properties of the case health system. It also highlighted specific leverage points at which HP policy and practice can be improved. This paper demonstrates the critical importance of leveraging leadership and governance for HP and adds urgency to the need for increased and strong advocacy efforts targeting all levels of government in multisectoral health systems.

Understanding the utilization of primary health care services by Indigenous men: a systematic review

BackgroundAboriginal and Torres Strait Islander men experience worse health outcomes and are the most marginalized and disadvantaged population group in Australia. Primary health care services are critical to providing both clinical and social and emotional support, however, remain underutilized by Aboriginal and Torres Strait Islander men. This review aims to better understand the utilization of primary health care services by Indigenous men and assess the effectiveness of strategies implemented to improve utilization.MethodsA four-step search strategy was employed across four databases to find peer-reviewed publications and grey literature from Australia, New Zealand, Canada and America. The search began in March 2015 and included the following databases PubMed, CINAHL, Informit (Indigenous collection) and Embase. Additional databases and websites were also searched for grey literature, reference lists of included publications were searched for additional studies and relevant experts were consulted.ResultsThe literature search found seven articles that met the inclusion criteria; four describing three research projects, plus three expert opinion pieces. The search was unable to find published research on strategies implemented to improve primary health care utilization by Indigenous men.There is limited published research focused on the utilization of primary health care by Indigenous men. From the identified papers Indigenous men described factors impacting utilization which were categorized into three primary organizing themes; those related to health services, the attitudes of Indigenous men and knowledge. It is evident from the identified papers that improvements in Indigenous health can only occur if future programs are developed in collaboration with health services and Indigenous men to address differing requirements.ConclusionsCurrently, health systems in Australia are limited in their ability to improve the health and wellbeing of Aboriginal and Torres Strait Islander males without such strategies. Future research should focus on evaluating the implementation of men specific utilization strategies. It is through evidence-based research that subsequent policies and programs can be made and implemented to improve Indigenous men’s health.

Public Health Costs for Northern Territory and South Australian Cardiac Surgery Patients

The cost of performing cardiac surgery in the public health system in Australia is unclear. This paper analyses the cost of cardiac surgery performed at Flinders Medical Centre (FMC), South Australia, comparing cost by procedure, rheumatic valvular heart disease status, Aboriginality and location. This study is a retrospective, population-based analysis of cardiac surgery data held in the Cardiac Surgery Registry cross-referenced to cost data provided by the FMC Department of Finance and Patient Travel, Accommodation and Transport Services at the Royal Darwin Hospital. Seven hundred ninety-five (795) patients who underwent cardiac surgery at FMC from 1 July 2014 to 30 June 2016 were included. Across all procedures, Northern Territory (NT) Aboriginal patients had a mean total cost of $78,506 which was $24,113 more than NT non-Aboriginal, $28,443 more than South Australian (SA) Aboriginal and $22,955 more than SA non-Aboriginal patients. The total cost of a patient undergoing a repeat sternotomy (reoperative procedure) was found to be significantly higher than a primary procedure ($85,797 versus $59,097). In patients undergoing valve surgery procedures, those identified with rheumatic heart disease had a higher mean total cost than those without (a difference of $25,094). Significantly, the rheumatic patient group showed a higher proportion of reoperative procedures (19% versus 5%). The cost of treating NT Aboriginal cardiac surgical patients remotely has a significant financial impact upon the health care delivery system, as does the impact of rheumatic heart disease. This study found that the cost for the NT Aboriginal patient group was substantially higher than the NT non-Aboriginal, SA Aboriginal and SA non-Aboriginal patient groups. The additional cost to family and dislocation of social structures is not able to be calculated, but would also clearly weigh heavily on both patient groups. These findings suggest that future health funding models should recognise Aboriginality, remoteness and rheumatic heart disease.

‘Hope givers’? A scoping review of new media and mental health in 27 Australian Christian organisations

ABSTRACTThis article explains a range of conceptual and methodological innovations in the use of new media for the clinical practice and public communication of mental health. Building on two current contexts – the emerging research area of new media and mental health, and major reform of the mental health system in Australia – this article presents a scoping review of the online communication of Christian organisations that offer mental health care in Australia. This article compares the websites of 27 Australian Christian mental health organisations, analysing these organisations’ configurations of mainstream and religious modalities of mental health care, their discursive and visual communication strategies, as well as their use of social media platforms.

Pricing for safety and quality in healthcare: Adiscussion paper.

Increasingly, over the past decade, there has been a global shift in healthcare away from fixed "fee for service" payment mechanisms towards value-based reimbursement models rewarding safety and quality patient outcomes. Curbing the burgeoning costs of healthcare while incentivising higher quality and safer patient care are key drivers of this approach. At face value, this is clearly a worthwhile endeavour. However, there is a lack of conclusive evidence to support the effectiveness of such schemes where they have been introduced internationally. For this reason, Australia has largely been an observer of the shift in payment modalities that are occurring in other countries such as the United States and the United Kingdom. This paper presents an overview of current Australian practice in pricing for safety and quality in Healthcare. Recommendations are provided to help infection control professionals prepare for the upcoming introduction of funding reforms aimed at reducing complications acquired in Australian public hospitals. The implications for infection control professionals are wide-ranging. This will be a period of significant adjustment for the public health system in Australia.

Negotiating health and chronic illness in Filipino-Australians: a qualitative study with implications for health promotion

ABSTRACTObjective: In spite of the healthy immigrant effect, the prevalence of lifestyle-related chronic diseases among migrants is reported to approximate that of the host country with longer duration of stay. For example, higher rates of chronic diseases such as Type 2 diabetes and hypertension have been observed among Filipino migrants and these have been linked to acculturation. The aim of this study was to explore the experiences of Filipino-Australian migrants in managing their chronic health conditions in a Western host country.Design: This paper reports on qualitative findings of a mixed methods study that used an explanatory sequential design. Nine focus group discussions were undertaken with 58 Filipino-Australian migrants with chronic disease. Thematic analysis was undertaken using a five-stage general purpose thematic framework ensuring that themes closely identified key participants’ experiences.Results: Findings revealed that health benefits provided by the health system in Australia were considered advantageous. However, a lack of social and instrumental support compounded isolation and disempowerment, limiting self-management strategies for chronic illnesses. Cultural beliefs and practices influenced their knowledge, attitude to and management of chronic disease, which health service providers overlooked because of perceived acculturation and English language skills. Overall this study has clearly identified recognition of cultural beliefs, language needs and support as three core needs of Filipino-Australian migrants with the elderly the most vulnerable.Conclusion: This paper highlights that self-management of chronic disease among elderly Filipino immigrants may be adversely affected by host language difficulties, a lack of social support and cultural issues, impacting on access to services, health-seeking behaviours and participation in health promotion initiatives. Language, culture-specific health interventions and resources and enhancing social support are likely important strategies in promoting chronic disease self-management among the elderly. These interventions have the potential to empower and encourage individuals to take control and better manage their chronic disease.

Clinical change after the implementation of the Choice and Partnership Approach within an Australian Child and Adolescent Mental Health Service.

The Choice and Partnership Approach (CAPA) model has been implemented widely into Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom and similar health systems in Australia and New Zealand. This study investigated whether the implementation of the CAPA model was related to changes in client clinical outcomes and response times within a regional Australian CAMHS. Multiple measures of time, clinical diagnosis, contact and outcomes were collected at intake and discharge for 33 clients prior to and 77 following the implementation of CAPA. A two-tailed t-test showed that the significantly reduced waiting time was associated with the timing of CAPA implementation. The Health of the Nation Outcome Scales for Children and Adolescents information subscale showed a significant post-CAPA implementation improvement. A chi-square test for independence showed that the CAPA model group had significantly more initial clinical appointments. After the implementation of CAPA, the flow of young people through the service improved, with children and adolescents being seen in a more timely manner. The findings highlighted that the greater client throughput did not negatively impact upon clinical outcomes. Further prospective research with the completion of multi-informant outcome measures is recommended.

Health Systems in Australia and Four Other Countries: choices and challenges

The purpose of health systems is the pursuit of healthy lives. The performance of the Australian health system over the last decade is compared with the United Kingdom and its three other offshoots: the United States, Canada and New Zealand. In the first instance, system performance is assessed in terms of threats to healthy lives from risk factors and changes that have taken place during the decade. In view of the emphasis of the five systems on the return to health after trauma and illness, and the human-resource intensity of health services, an appraisal is made of changes in the number of the major health professionals in relation to the growing populations. Then related changes in hospital, medical practitioner and dentist services are assessed. Changes in pharmaceutical drug prescriptions in Australian are also examined. The levels of national expenditures arising from the provision health services are then considered in the context of the costs of administration of the varied organisational modes, use of expensive medical technologies, pharmaceutical drug consumption and remuneration of health professionals. Finally, health outcomes in Australia and the other four countries are assessed in accordance with their human development level, life expectancy, potential years of life lost from different causes, as well as healthy life expectancies. Further, gaps in health and life expectancy of Indigenous people in the United States, Canada, New Zealand and Australia are reviewed, as well as health and survival inequalities among people in different social strata in each country.
 Abbreviations: GDP – Gross Domestic Product; HDI – Human Development Index.

Current patient and healthcare worker attitudes to eHealth and the personally controlled electronic health record in major hospitals.

The current health system in Australia is comprised of both electronic- and paper-based medical records. The Federal Government has approved funding for the development of an individual health identifier and a universally adopted online health repository. To determine attitudes and beliefs of patients and healthcare workers regarding the use of stored medical information and the personally controlled electronic health record (PCEHR) in selected major hospitals in Victoria. Qualitative survey of patients and healthcare workers (n = 600 each group) conducted during 2014 across five major hospitals in Melbourne to measure the awareness, attitudes and barriers to electronic health and the PCEHR. Of the patients, 93.3% support the concept of a shared electronic healthcare record, 33.7% were aware of the PCEHR and only 11% had registered. The majority of healthcare workers believed that the presence of a shared health record would result in an increased appropriateness of care and patient safety by reducing adverse drug events and improving the timeliness of care provided. However, only 46% of healthcare workers were aware of the PCEHR. This study provides a baseline evaluation of perceptions surrounding eHealth and PCHER in acute health services in five metropolitan centres. While there appears to be a readiness for adoption of these strategies for healthcare documentation, patients require motivation to register for the PCEHR, and healthcare workers require more information on the potential benefits to them to achieve more timely and efficient care.

Platelet-rich plasma: a case study for the identification of disinvestment opportunities using horizon scanning.

Objective This paper discusses the potential for horizon scanning to identify low-value, inappropriate clinical practices that deliver minimal benefit to patients and represent a considerable financial burden on the health system. Methods Platelet-rich plasma (PRP) was identified by routine horizon scanning as a potentially innovative treatment alternative for osteoarthritis of the knee. A rapid, non-systematic assessment of the evidence pertaining to the safety and effectiveness of PRP compared with nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of osteoarthritis of the knee was conducted. Results The evidence base supporting the use of PRP for the treatment of osteoarthritis was poor. No comparative studies were identified that compared the use of PRP to NSAIDs, the current treatment option for osteoarthritis of the knee in Australia. Despite the lack of effectiveness evidence, the use of PRP injections was rapidly increasing in the private sector using an inappropriate Medicare Benefits Schedule item number. Conclusions This assessment highlights the potential of using established horizon scanning methodologies to identify targets for full or partial disinvestment of ineffective, inefficient or harmful clinical practices. What is known about the topic? PRP is rapidly diffusing in the private health system in Australia, however the use of a Medicare Benefits Schedule item number meant that this practice was being subsidised by the public reimbursement of treatment fees. What does this paper add? Traditional horizon scanning tends to identify technologies for health systems to invest in. The evidence on the effectiveness of PRP was examined with the purpose of exploring investment in an innovative treatment that may have reduced the number of invasive procedures being performed in the public hospital system. The current evidence base does not support the use of PRP injections for the treatment of osteoarthritis. It does, however, support the use of horizon scanning as an inexpensive methodology to identify possible disinvestment targets associated with potential patient harm and high health service expenditure. What are the implications for practitioners? Practitioners should be aware that public funding for the injection of PRP should not be used for the treatment of osteoarthritis.

Information giving challenges and support strategies at the time of a mental health diagnosis: qualitative views from Australian health professionals.

Communication of a mental health diagnosis can be a difficult process and is a poorly understood area of service provision. The aim of this qualitative study was to examine clinicians' perceptions of barriers and helpful strategies to discussing information about a mental health condition. Qualitative interviews with 19 Australian clinicians (general practitioners, mental health nurses, psychiatrists, and psychologists) working in several settings (community, hospital inpatient, outpatient, accident and emergency) and locations (urban, suburban and rural) were conducted and analysed thematically. After theme saturation was reached, four primary themes relating to barriers and facilitators to communication at the time of diagnosis were identified in the data. Outside a recognised lack of focus on this area in training, themes included (1) engagement and timing of conversations; (2) stigma and its reduction; (3) perceived and desired knowledge for diagnostic information; and (4) working with distress. The synthesis of themes is demonstrated in a flowchart of suggestions for communicating news of mental health diagnosis that tracks the patient journey in receiving information from initial engagement to follow-up. Talking with an individual about a mental health diagnosis is a non-linear, complex and changeable situation. However, health professionals report using specific strategies to aid this communication process, to meet the specific individual's needs. Strategies such as tailoring to the person's situation, utilising collaborative practice, effective coordination, and addressing stigma may be useful to inform clinician training and support whilst diagnosis remains a key feature of the mental health system in Australia.

Mendorong Sistem Jaminan Kesehatan Nasional Baru di Indonesia; Belajar dari Pengalaman Australia

Significant change of Indonesian economy has lead to the need of people more than just basic need such as food and clothes. Others such as health and education have become a must for Indonesian. Anticipating this condition, government will implement new universal coverage health system in 2014 as mandated by law. This paper has objectives to explore several aspects which contribute or influence to the policy formulation and implementation, particularly in designing new health insurance system in Indonesia and learning from Australian experience and best practice. Methodology used in this paper is both primary research such as in depth interview with some health economist, expert form universities, government researcher as well as observation to the organization that manage health system in Australia and secondary research by doing literature review of health insurance system, benchmarking, compare and contrast the health insurance system in Indonesia and Australia and analyze the best and suitable ones for implemented in the future. There are several interesting findings that can be recommended such as Australian health reform and relationship between public and private health system.

Incidence and prevalence of non-melanoma skin cancer in Australia: A systematic review.

Non-melanoma skin cancer (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common cancer occurring in people with fair skin. Australia has been reported to have the highest incidence of NMSC in the world. Using a systematic search of the literature in EMBASE and Medline, we identified 21 studies that investigated the incidence or prevalence of NMSC in Australia. Studies published between 1948 and 2011 were identified and included in the analysis. There were six studies that were conducted on national level, two at state level and 13 at the regional level. Overall, the incidence of NMSC had steadily increased over calendar-years in Australia. The incidence of NMSC per 100,000 person-years was estimated to be 555 in 1985; 977 in 1990; 1109 in 1995; 1170 in 2002 and 2448 in 2011. The incidence was higher for men than women and higher for BCC than SCC. Incidence varied across the states of Australia, with the highest in Queensland. The prevalence of NMSC was estimated to be 2% in Australia in 2002. The incidence and prevalence of NMSC still need to be accurately established at both national and state levels to determine the costs and burden of the disease on the public health system in Australia.

Moving university campuses tobacco‐free: collective responsibility and collaboration the key to a healthier Victoria

Full article Smoking is Victoria's leading preventable cause of death and continues to kill 4,000 Victorians every year.1 In a demonstration of public health leadership, all Victorian universities have recently joined forces in the implementation of the Victorian Universities Tobacco-Free Initiative to contribute to reducing the burden from tobacco-related disease in Victoria. The reach of Victorian universities to implement public health initiatives is significant and growing, with nearly 300,000 students and more than 40,000 academic and professional staff, as is the potential for universities to influence the heath behaviours of young people in a period where life-long behaviours are formed. This is particularly important, given that Victorians of university age (aged 18–29 years) are more likely to smoke than people aged 30–49 years and 50+ years.2 The Initiative educates and engages students and staff on the benefits of reducing smoking, supports smokers to quit and creates smoke-free campuses. This approach is more than just asking students and staff to leave the campus to have a cigarette; it provides a comprehensive suite of supports to help smokers quit that is likely to have a real impact on reducing harm from tobacco. The Tobacco-Free Initiative approach is collaborative across all universities and has been designed and implemented in association with university communities. An advantage of adopting a settings-based health promotion approach is that real changes can be implemented at local level without the need for government intervention or new legislation. Health promotion approaches driven by the community are efficient, timely and allow flexibility. Like the approach used in the Initiative, they create an environment that encourages healthy choices, and supports changes in communities that will have a positive impact on individuals, and also households, families, friends and broader networks. Therefore, this approach is not about helping one individual – it is about supporting a community to be healthier. The prevalence of chronic disease is increasing in Victoria.3 Cardiovascular disease, diabetes and chronic kidney disease share many common lifestyle-related risk factors and contribute a large proportion of the disease burden.4 Lifestyle factors such as tobacco smoking, excessive alcohol use, unhealthy diet and lack of physical activity contribute to the chronic disease burden.5 The direct health costs and lost productivity from smoking add up to $2.4 billion annually in Victoria alone.1 These costs are incurred across businesses, governments and by individuals. Given the recent concern about the sustainability of the health system in Australia, the costs attributable to smoking need to be addressed immediately. Victorian universities are doing their bit to help. The Victorian Universities Tobacco-Free Initiative provides an effective framework for universities to continue to work together and demonstrate public health leadership in developing settings-based health promotion approaches to address the increasing incidence of chronic disease and lifestyle-related risk factors. The unprecedented degree of collaboration between Australian universities over this initiative also allows them to share resources and wisdom and to jointly evaluate the programs in place. This not only expedites the development and roll out of tobacco-free programs, but builds a very sound evidence-base for the most effective strategies in these settings. The framework provides guidance for other industries in Victoria to work together to support the implementation of collaborative health promotion initiatives. The gravity of the future health, social and economic burden of chronic disease requires a timely and continued investment by government, but also by the private sector. The universities of Victoria encourage other major employers to join them and take an active role in developing environments that promote health for all Victorians. References 1 Collins DJ, Lapsley HM. The Social Costs of Smoking in Victoria in 2008/09 and the Social Benefits of Public Policy Measures to Reduce Smoking Prevalence. Melbourne (AUST): Quit Victoria and the VicHealth Centre for Tobacco Control; 2011. 2 Emily Bain SD, Wakefield M. Smoking Prevalence and Consumption in Victoria: Key Findings from the 1998–2012 Population Surveys. Melbourne (AUST): Victorian Department of Health; 2013. 3 Department of Health. Victorian Population Health Survey 2010. Melbourne (AUST): State Government of Victoria; 2012. 4 Australian Institute of Health and Welfare. Chronic Diseases and Associated Risk Factors in Australia, 2001. Canberra (AUST): AIHW; 2012. 5 Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, The Burden of Disease and Injury in Australia 2003. Canberra (AUST): Australian Institute of Health and Welfare; 2007.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

ObjectivesDespite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore...

Building a stronger child dental health system in Australia: statistical sampling masks the burden of dental disease distribution in Australian children

In Australia, over the past 30 years, the prevalence of dental decay in children has reduced significantly, where today 60-70% of all 12-year-olds are caries free, and only 10% of children have more than two decayed teeth. However, many studies continue to report a small but significant subset of children suffering severe levels of decay. The present study applies Monte Carlo simulation to examine, at the national level, 12-year-old decayed, missing or filled teeth and shed light on both the statistical limitation of Australia's reporting to date as well as the problem of targeting high-risk children. A simulation for 273 000 Australian 12-year-old children found that moving from different levels of geographic clustering produced different statistical influences that drive different conclusions. At the high scale (ie state level) the gross averaging of the non-normally distributed disease burden masks the small subset of disease bearing children. At the much higher acuity of analysis (ie local government area) the risk of low numbers in the sample becomes a significant issue. The results clearly highlight the importance of care when examining the existing data, and, second, opportunities for far greater levels of targeting of services to children in need. The sustainability (and fairness) of universal coverage systems needs to be examined to ensure they remain highly targeted at disease burden, and not just focused on the children that are easy to reach (and suffer the least disease).

Principles for the development of Aboriginal health interventions: culturally appropriate methods through systemic empathy

Objective. To increase Aboriginal participation in mainstream health services, it is necessary to understand the factors that influence health service usage. This knowledge can contribute to the development of culturally appropriate health services that respect Aboriginal ways of being.Design. We used a community-based participatory approach to examine the reasons for underutilization of health services by Aboriginal Australians.Results. Based on three focus groups and 18 interviews with Aboriginal health professionals, leaders, and community members in rural, regional, and urban settings, we identified five factors that influenced usage, including (1) negative historical experiences, (2) cultural incompetence, (3) inappropriate communication, (4) a collective approach to health, and (5) a more holistic approach to health.Conclusion. Given that these factors have shaped negative Aboriginal responses to health interventions, they are likely to be principles by which more appropriate solutions are generated. Although intuitively sensible and well known, these principles remain poorly understood by non-Aboriginal health systems and even less well implemented. We have conceptualized these principles as the foundation of an empathic health system. Without empathy, health systems in Australia, and internationally, will continue to face the challenge of building effective services to improve the state of health for all minority populations.

Law Reform or Systemic Reform? Stakeholder Perceptions of Resource Constraints in Mental Health in Australia, New Zealand and Canada

This article examines resource constraints in the mental health systems in Australia, New Zealand and Canada in light of the results of a qualitative study analysing interviews with 65 representatives of consumer and carer organisations, lawyers, judges and mental health professionals conducted between September 2008 and December 2010. The interviews were analysed using grounded theory, and an unanticipated finding was that resource constraints in mental health law and practice emerged as the most discussed theme. The analysis revealed that participants were concerned about (1) the futility of law reform without the injection of adequate resources in their mental health systems; (2) the types of resources that they perceived were lacking; and (3) the consequences of those resource constraints on the operation of mental health systems at a systemic level. This paper highlights the importance of systemic factors in the development of mental health law, policy and practice.

Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals

Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip- and total knee-replacement surgery in South Australian public-funded hospitals. Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework. System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy. Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful. WHAT IS KNOWN ABOUT THE TOPIC? Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn't clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform. WHAT DOES THIS PAPER ADD? This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip- and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region- or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians should experience a more streamlined approach to referral for and receipt of elective surgery in public hospitals. The consistency with which barriers and facilitators were identified across the four hospitals involved in this research supports the generalisability of the results. This further suggests that although specific to hip and knee replacement, many of the same barriers and facilitators could be in place across numerous surgical and non-surgical disciplines.

Good governance of animal health systems and public-private partnerships: an Australian case study

The animal health system in Australia has evolved over more than 100 years and includes innovative public-private partnership arrangements. The establishment in 1996 of Animal Health Australia (AHA), a not-for-profit company, was a crucial development which formalised arrangements for shared decision-making and funding across both government and industry stakeholders. However, Federal and State governments retain legislative authority for animal health control. Accordingly, all programmes must recognise that the public sector remains an executive arm of government, accountable for its actions. Hence, much effort has been invested in ensuring that the governance arrangements within AHA are lawful and transparent. The Emergency Animal Disease Response Agreement (EADRA) is a very good example of governance arrangements that are sustainably financed, widely available, provided efficiently, without waste or duplication, and in a manner that is transparent and free of fraud or corruption. The benefits of EADRA include certainty and greater transparency of funding; greater efficiency through increased probability of a rapid response to an occurrence of any of 65 diseases; and industry participation in the management and financing of such a response.