Hospitals Reform Commission Research Articles

Harnessing fast and slow thinking to ensure sustainability of general practice and functional universal health coverage in Australia.

Harnessing fast and slow thinking to ensure sustainability of general practice and functional universal health coverage in Australia.

Collaborative Commissioning: regional funding models to support value‐based care in New South Wales

Collaborative Commissioning: regional funding models to support value‐based care in New South Wales

Federalism and Australia’s National Health and Health Insurance System

While health reform in Australia has been marked by piecemeal, incremental changes, the overall trend to increasing Commonwealth involvement has not been accidental or driven by power-hungry centralists: it has been shaped by broader national and international developments including technological change and the maturing of our nation and its place internationally, and by a widespread desire for a national universal health insurance system. In many respects the Australianhealth system performs well, but the emerging challenges demand a more integrated, patient-oriented system. This is likely to require a further shift towards the Commonwealth in terms of financial responsibility, as the national insurer. But it also requires close cooperation with the States, who could play a firmer role in service delivery and in supporting regional planning and coordination. The likelihood of sharing overall responsibility for the health system also suggests thereis a need to involve the States more fully in processes for setting national policies.
 This article draws heavily on a lecture presented at the Australian National University in October 2015. It includes an overview of Australia’s evolving federal arrangements and the context within which the current Federalism Review is being conducted. It suggests Australia will not return to ‘coordinate federalism’ with clearly distinct responsibilities, and that greater priority should be given to improving how we manage shared responsibilities.
 There is a long history of Commonwealth involvement in health, and future reform should build on that rather than try to reverse direction. While critical of the proposals from the Commission of Audit and in the 2014 Budget, the lecture welcomed the more pragmatic approaches that seemed to be emerging from the Federalism Review discussion papers and contributions from some Premiers which could promote more sensible measures to improve both the effectiveness and the financial sustainability of Australia’s health and health insurance system.
 The Commonwealth’s new political leadership in 2015 seemed interested in such measures and in moving away from the Abbott Government’s approach. But the legacy of that approach severely damaged the Turnbull Government in the 2016 federal election as it gave traction to Labor’s ‘Mediscare’ campaign. In addition to resetting the federalism debate as it affects health, the Turnbull Government now needs to articulate the principles of Medicare and to clarify the role of the private sector, including private health insurance, in Australia’s universal health insurance system. Labor also needs to address more honestly the role of the private sector and develop a more coherent policy itself.
 Abbreviations: COAG – Council of Australian Governments; NHHRC – National Health and Hospitals Reform Commission; PHI – Private Health Insurance; VFI – Vertical Fiscal Imbalance.

Pre hospital medical services and paramedic engagement in Australian health care - Improving the pathways of care through collaborative action

Pre hospital medical services and paramedic engagement in Australian health care - Improving the pathways of care through collaborative action

Best-practice integrated health care governance - applying evidence to Australia's health reform agenda.

Internationally, health reform initiatives have identifi ed improved integration between community and acute care delivery as key to sustainability.1,2 Australian reform initiatives have been no exception. In 2009, Australia’s National Health and Hospitals Reform Commission laid the “blueprint” for Australia’s health care future.3 It stressed the importance of “connecting and integrating health and aged care services for people over their lives”. However, it also observed that “each level of government formulates policy in relation to its own responsibilities, not necessarily taking account of the health system as a whole”, and that “current governance arrangements are contributing directly to weaknesses in the quality, effectiveness and effi ciency of the Australian health system”.3 Three years later, the National Healthcare Agreement 2012 committed all federal, state and territory governments to support an integrated approach to the promotion of healthy lifestyle, and prevention, diagnosis and treatment of illness across the continuum of care.4 Despite the critical nature of joint community and acute care cooperation in delivering on the plethora of mutually agreed objectives, there was no mention of any commitment to the integrated governance arrangements pivotal to such success. Concurrently, Australia’s fi rst National Primary Health Care Strategy established a network of 61 primary health care organisations, Medicare Locals (MLs), across Australia.5 While the Strategy stated that MLs “will be an integral component of the National Health and Hospitals Network” and “have some common governance membership with the Local Hospital Networks [LHNs] in their region”, an integrated governance model was never developed.5 Given the priority placed on effective governance frameworks to deliver clear roles and responsibilities to both funders and providers of health care, what is the governance vehicle best suited to achieving our national reform outcomes, and how is it best crafted in the current Australian health care reality? In 2013, we conducted a systematic review to explore international peer-reviewed articles and relevant websites for effective and sustainable integrated primary–secondary health governance models. Ten key elements were identifi ed, many interdependent, from 21 articles that met the inclusion criteria.6 The evidence suggests the following specifi c governance elements are important to support integrated care across the primary–secondary care continuum: • Joint planning was identifi ed as key in 18 of the 21 articles. Governance arrangements included formal agreements such as memoranda of understanding (MOUs), joint board memberships and multilevel partnerships in the planning process. • Integrated information communication technologies were noted in 17 articles, particularly, a shared electronic health record, and systems that link clinical and fi nancial measures. • Effective change management was noted in 17 articles, requiring a shared vision, leadership, time and committed resources to support implementation. • Sixteen studies agreed on the importance of shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care. • Aligning incentives to support the clinical integration strategy, noted in 15 studies, includes pooling multiple funding streams and creating equitable incentive structures. • Providing care across organisations for a geographical population, noted in 13 articles, required a form of enrolment, maximised patient accessibility and minimised duplication. • Use of data as a measurement tool across the continuum for quality improvement and redesign, found in 12 studies, requires agreement to share relevant data. • Professional development supporting joint working, supported by 11 articles, allowed alignment of differing cultures and agreement on clinical guidelines. • An identifi ed need for consumer/patient engagement, noted in eight studies, is achieved by encouraging community participation at multiple governance levels. • One-third of articles acknowledged the need for adequate resources to support innovation to allow adaptation of evidence into care delivery.6

Investing in acute health services: is it time to change the paradigm?

Capital is an essential enabler of contemporary public hospital services funding hospital buildings, medical equipment, information technology and communications. Capital investment is best understood within the context of the services it is designed and funded to facilitate. The aim of the present study was to explore the information on capital investment in Australian public hospitals and the relationship between investment and acute care service delivery in the context of efficient pricing for hospital services. This paper examines the investment in Australian public hospitals relative to the growth in recurrent hospital costs since 2000-01 drawing from the available data, the grey literature and the reports of six major reviews of hospital services in Australia since 2004. Although the average annual capital investment over the decade from 2000-01 represents 7.1% of recurrent expenditure on hospitals, the most recent estimate of the cost of capital consumed delivering services is 9% per annum. Five of six major inquiries into health care delivery required increased capital funding to bring clinical service delivery to an acceptable standard. The sixth inquiry lamented the quality of information on capital for public hospitals. In 2012-13, capital investment was equivalent to 6.2% of recurrent expenditure, 31% lower than the cost of capital consumed in that year. Capital is a vital enabler of hospital service delivery and innovation, but there is a poor alignment between the available information on the capital investment in public hospitals and contemporary clinical requirements. The policy to have capital included in activity-based payments for hospital services necessitates an accurate value for capital at the diagnosis-related group (DRG) level relevant to contemporary clinical care, rather than the replacement value of the asset stock. WHAT IS KNOWN ABOUT THE TOPIC?: Deeble's comprehensive hospital-based review of capital investment and costs, published in 2002, found that investment averages of between 7.1% and 7.9% of recurrent costs primarily replaced existing assets. In 2009, the Productivity Commission and the National Health and Hospitals Reform Commission (NHHRC) recommended capital, for the replacement of buildings and medical equipment, be included in activity-based funding. However, there have been persistent concerns about the reliability and quality of the information on the value of hospital capital assets. WHAT DOES THIS PAPER ADD?: This is the first paper for over a decade to look at hospital capital costs and investment in terms of the services they support. Although health services seek to reap dividends from technology in health care, this study demonstrates that investment relative to services costs has been below sustainable levels for most of the past 10 years. The study questions the helpfulness of the highly aggregated information on capital for public hospital managers striving to improve on the efficient price for services. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Using specific and accurate information on capital allocations at the DRG level assists health services managers advance their production functions for the efficient delivery of services.

Are we there yet? A journey of health reform in Australia

• Five years on from the establishment of the National Health and Hospitals Reform Commission, it is timely to review the context for reform and some of the actions taken to date, and to highlight remaining areas of concern and priority. • The Commission's final report was released in July 2009 and presented 123 recommendations organised under four reform themes: Taking responsibility: individual and collective action to build good health and wellbeing - by people, families, communities, health professionals, employers, health funders and governments Connecting care: comprehensive care for people over their lifetime Facing inequities: recognise and tackle the causes and impacts of health inequities Driving quality performance: leadership and systems to achieve best use of people, resources and evolving knowledge. • Overall, the Australian Government's response to the Commission's report has been very positive, but challenges remain in some key areas: Financial sustainability and the vertical fiscal imbalance between the federal and state governments Getting the best value from the health dollar by reducing inefficiency and waste and using value-based purchasing across the public and private health sectors National leadership across the system as a whole Getting the right care in the right place at the right time Health is about more than health care - increasing focus on prevention and recognising and tackling the broader social determinants of health.

It will never happen to us: the likelihood and impact of privacy breaches on health data in Australia.

With the recent introduction of the Australian e-health system, health reforms and legislation were passed. Whilst the aim of these health reforms was reasonable and sensible, the implementation was rushed and less than perfect. The Deloitte e-health Strategy [1] which was endorsed by the National Health and Hospital Reform Commission (NHHRC) recommended that based on international experience implementation of shared electronic health records nationally was a ten year journey. In Australia this was condensed into two years. The resultant effect has been that privacy, which is essential for the uptake of technologies to share data in a compliant manner, may be compromised. People trust transparent systems. Where there is a breach in privacy people deserve the respect and right to know about it so that they can mitigate damages and with full disclosure, retain their trust in the system. If this is not evident, the public will refuse to share their information. Hence, whilst the technologies may work, their use may be limited. The consequence of this in Australia would be the continuance of dangerous and inefficient silos of health data.

Reforming the mission of public dental services

Australia has a complex history of providing public dental services to its communities. From the early days of Colonial settlement, the provision of dental care to the Australian public has largely been driven and influenced by organized groups and associations of dentists. The Constitution of Australia, under Section 51 xxiii A, allows for the Commonwealth to provide for medical and dental services. Unlike the United Kingdom, however, dental services have not been embedded into a universal national health service agenda. In 1974, that the Australian Government through the Australian School Dental Program provided the first funding and national direction for public dental services - and that, limited to children. The Commonwealth Dental Health Program 1993-1997 was the second national endeavor to provide public dental services, this time to financially disadvantaged adults. Since that time, public dental service responsibility has been shuttled between States/Territories and the Commonwealth. A new paradigm for public dental services in Australia requires strong Commonwealth leadership, as well as the commitment of State and Territories and the organized dental profession. The National Health and Hospitals Reform Commission provided the most recent scenario for a radical change in mission. This paper canvases the competing roles of strategic, functional, and structural issues in relationship to social network and policy issues, which must be recognized if Australians truly seek to reform public dental services.

Encouraging participation in health system reform: is clinical engagement a useful concept for policy and management?

Recent health system enquiries and commissions, including the National Health and Hospital Reform Commission, have promoted clinical engagement as necessary for improving the Australian healthcare system. In fact, the Rudd Government identified clinician engagement as important for the success of the planned health system reform. Yet there is uncertainty about how clinical engagement is understood in health policy and management. This paper aims to clarify how clinical engagement is defined, measured and how it might be achieved in policy and management in Australia. We review the literature and consider clinical engagement in relation to employee engagement, a defined construct within the management literature. We consider the structure and employment relationships of the public health sector in assessing the relevance of this literature. Based on the evidence, we argue that clinical engagement is similar to employee engagement, but that engagement of clinicians who are employees requires a different construct to engagement of clinicians who are independent practitioners. The development of this second construct is illustrated using the case of Visiting Medical Officers in Victoria. Antecedent organisational and system conditions to clinical engagement appear to be lacking in the Australian public health system, suggesting meaningful engagement will be difficult to achieve in the short-term. This has the potential to threaten proposed reforms of the Australian healthcare system.

Regarding ‘National Health and Hospital Reform Commission final report and patient-centred suggestions for reform’ by T. Jowsey, L. Yen, R. Wells and S. Leeder

The recently published article by Jowsey et al. (2011, Australian Journal of Primary Health 17, 162-168) highlighted key inclusions and omissions from the National Health and Hospital Reform Commission final report with respect to patient-centred care for people with chronic illness. However, the author proposes that this study could have further addressed dimensions of equity and patient-centred practice by including participants with chronic mental illness. The author suggests that interventions to improve chronic illness care typically remain disease specific, which fails to address the realities that face consumers or service providers. References to the literature and professional experience are provided to support the inclusion of mental illness within discussion, services and policy concerning chronic illness.

Evolution of advance care planning in Australia – launching the new international advance care planning and end of life care society

Although there were small areas of interest in advance care planning (ACP) and the ability to refuse treatment in Australia as early as 1987, the implementation of and research in,...

Making health choices; Part 1. Advance Care planning in aged care project. Setting the scene

IntroductionThe (2009) Australian National Health & Hospital Reform Commission Report highlighted the need for advance care planning (ACP) for older persons in residential aged care facilities (RACFs). Using knowledge gained...

National Health and Hospital Reform Commission final report and patient-centred suggestions for reform

The final report of the National Health and Hospital Reform Commission (NHHRC) called for a strengthened consumer voice and empowerment. This has salience for the development of health policy concerning chronic illnesses. This paper compares the recommendations for chronic illness care made in the NHHRC final report with suggestions made by people with chronic illness and family carers of people with chronic illness in a recent Australian study. Sixty-six participants were interviewed in a qualitative research project of the Serious and Continuing Illness Policy and Practice Study (SCIPPS). Participants were people with type II diabetes mellitus, chronic obstructive pulmonary disease or chronic heart failure. Family carers were also interviewed. Content analysis was undertaken and participants' recommendations for improving care were compared with those proposed in the NHHRC final report. Many suggestions from the participants of the SCIPPS qualitative research project appeared in the NHHRC final report, including the need to improve care coordination, health literacy and the experience of Indigenous Australians. The research project also identified important issues of family carers, immigrants and people with multiple illnesses, which were not addressed in the NHHRC final report. More specific attention is needed in health reform to improve the experience of family carers, Indigenous peoples, immigrants to Australia and people with multiple illnesses. To align more closely with their needs, health reform must be explicitly informed by the voices of people with chronic illness and their family carers. The NHHRC recommendations must be supplemented with proposals that address the needs of these people for support and the problems associated with poor care coordination.

Australia's private health insurance industry: structure, competition, regulation and role in a less than 'ideal world'

Australia's private health insurance funds have been prominent participants in the nation's health system for 60 years. Yet there is relatively little public awareness of the distinctive origins of the health funds, the uncharacteristic organisational nature of these commercial enterprises and the peculiarly regulated nature of their industry. The conventional corporate responsibility to shareholders was, until recently, completely irrelevant, and remains marginal to the sector. However, their purported answerability to contributors, styled as 'members', was always doubtful for most health funds. After a long period of remarkable stability in the sector, despite significant shifts in health funding policy, recent years have brought notable changes, with mergers, acquisitions and exits from the industry. The research is based on the detailed study of the private health funds, covering their history, organisational character and industry structure. It argues that the funds have always been divorced from the disciplines of the competitive market and generally have operated complacently within a system of comprehensive regulation and generous subsidy. The prospect of the private health funds enjoying an expanded role under a form of 'social insurance', as suggested by the National Health and Hospitals Reform Commission, is not supported.

The economics of primary healthcare reform in Australia – towards single fundholding through development of primary care organisations

A strong primary care sector is widely acknowledged as a fundamental component of a well functioning health system and thus has been the focus of strategic reforms in a number of countries. This paper provides an economic analysis of primary healthcare reform, with the aim of identifying the key structural elements that are necessary to support enhanced models of primary health in the Australian context. This paper utilises economic theory, and draws upon empirical evidence and international experience to analyse primary healthcare reform to identify the structural elements necessary for an enhanced primary care sector. The aim of which is to improve health system performance. These structural elements are then critically examined in the Australian health system setting. For enhanced models of primary healthcare to promote efficiency, they must incorporate a number of key structural elements; notably: governance and purchasing responsibilities for primary care devolved to a meso-level organisational structure through capitated single fundholding arrangements; blended payment methods for reimbursing providers; the establishment of a national quality and performance framework; and the development of primary care infrastructure. As the Federal government attempts to address recommendations of the National Health and Hospital Reform Commission, a window of opportunity now exists to pursue long overdue structural reforms to deal with the challenges facing the Australian health system. The paper advances the important structural features to primary healthcare that need to be embraced as the government attempts to pursue its health reform agenda.

Australian dental students views on a compulsory internship scheme

Objective: The National Health and Hospitals Reform Commission Report suggests introducing an internship period for all newly qualified dental/oral health practitioners in Australia. This study gauged the opinions of undergraduates from three dental schools in Australia. Methods: An online survey collected demographic information on gender and age, the program registered for, year and place of study. The level of support for an internship was gauged using a five-point scale. Open-ended questions on the concerns, advantages and disadvantages of an internship concluded the survey. All students in the participating universities were invited to participate via email. Results: There were 445 responses. Forty per cent of students were supportive of an internship scheme. The level of support differed by gender, age, relationship status, having a previous tertiary qualification and year of study. Males, older participants, those with children and those with previous qualifications were less supportive. The main concerns related to issues around choice, family commitments, location of internship placements and salary levels. Conclusion: Support for an internship scheme for dental graduates elicited a divided opinion amongst dental students. Many issues around financing and logistics have to be addressed before any such scheme could be implemented in Australia: there is a need to consult with dental graduates and promote the benefits to the student body.

Health reform and the Medical Journal of Australia

In 2008, the Australian Government established three major health reform initiatives - the National Health and Hospitals Reform Commission, the first National Primary Health Care Strategy working group, and the Preventative Health Taskforce. We examined which journals were most frequently cited in the publicly available discussion papers, commissioned papers, submissions and final reports of these initiatives. Journal articles were cited most in discussion papers, commissioned papers and submissions, followed by reports and other publications from Australian organisations and governments. The Medical Journal of Australia was the most cited journal, with 392 references to its articles (11.8% of all journal articles cited) in discussion papers, commissioned papers, submissions and an interim report, and 58 references to its articles (13.7% of total journal articles) in the three final reports. Our findings demonstrate the importance of credible, local, accessible, peer-reviewed evidence in reforming the national health system, including hospitals, primary health care and preventive health care.

Risks associated with low functional health literacy in an Australian population

Despite attention given to health literacy bythe National Health and Hospitals ReformCommission, current discussions remain wor-ryingly limited.In the 1990s, Nutbeam was prominentamong those who recognised both the indi-vidual and the larger environmental settingsof health literacy, as well as its relevance toprevention. “Health literacy and health skills”was included as a category in a landmarkhealth goals and targets framework, as “per-sonal health knowledge and positive attitudestowards changing behaviour demonstrablyinfluence people’s ability to adopt healthylifestyles”.

Fit for the future — a regional governance structure for a new age

Australia's health care system is at a crossroads. It is recognised that the fragmentation of health services, largely caused by the split between Commonwealth and state government funding responsibilities, is undermining patient care. The National Health and Hospitals Reform Commission (NHHRC) has advanced two models of health-system governance to redress this situation - neither incorporating the regional approach so prominent in submissions to the NHHRC and included in Option B of the NHHRC interim report. A regional governance framework such as that described in this paper could keep faith with the importance widely given to local engagement during the consultation process; sit neatly within the NHHRC's Healthy Australia Accord option; make regions responsible for funding allocation and service delivery; eliminate major weaknesses in our current system; and provide stability to the system at a time of significant reform.