Greater transparency and consultation needed in health service
In our third special feature on healthcare in Australia, Prue Power, the executive director of the Australian Healthcare Association, speaks exclusively to Rodney Appleyard from MedicalSearch.com about the need for greater transparency and community consultation in the health system.
A major challenge for the Australian healthcare system is lack of transparency around resource constraint. Resource constraint is not simply an issue of providing more money. There will always be more things that it is possible to do to improve healthcare, no matter how large the overall health budget. It has been necessary for health service providers to make rationing decisions in response to this open-ended demand. At the same time there has been a tendency to deny that demand is constrained.
Individual health service providers get their satisfaction, professional identity and income from these services and so are unlikely to wish to acknowledge resource limitation. Equally, politicians are often reluctant to face this issue, presumably for fear of electoral backlash. These motivations inhibit the provision of information about resource utilisation. Greater transparency is required about health costs and the benefits that accrue so that the community can determine whether it wants to spend more (or less) money on health compared to transport, education, tax cuts etc.
A nation’s health policy should aim for “optimal” health for its population. The term “optimal” recognises that, while it is technically possible to achieve health gains for some individuals in a community, it is not always possible to deliver the required services because of resource constraint. Even with this recognition, further clarification of the idea of “optimal” is required. For example, does our community wish to invest in an initiative which may result in a large net, but small individual, improvement in the health of the community as a whole; or would the community prefer a smaller net, but larger individual improvement, in the health of that section of the community with the worst health outcomes? This question is far from theoretical.
To date there have not been clear objectives for the Australian healthcare system. To the extent that objectives have been considered there has often been a lack of community consultation and transparency. The issue of engaging the community in determining what its health priorities are is a major challenge for Australia’s health policy.
A comprehensive consultation process with the community should be absolutely central to any reform. Currently, there is no systematic process to obtain the views of the Australian community on their priorities. Despite the fact consumers are both the funders and the users of health care, Governments and policy makers do not have a good idea of what the community wants from the health system. This is a serious gap.
There are many tough questions that need to be asked in allocating health funding. Should we be putting more resources into saving premature babies or into reducing the rate of smoking in the community? Should we increase access to health care to rural and remote communities, if this means reducing access for those living in cities?
Unless we have a community debate about these issues, we will not have a health funding system that truly reflects the views and priorities of the Australian people.
There are many examples of how community consultation on health priorities can work. Some of these, such as the “Oregon Experiment” in the United States, have been fairly controversial.
However, there are two recent examples of successful community involvement in determining broad priorities for health system funding which are discussed briefly below. These are the Romanow Commission in Canada and a smaller scale Citizens' Juries project in Western Australia.
Canada - Romanow Commission: The Commission on the Future of Health
Care in Canada (commonly called the Romanow Commission) was an independent Royal Commission established in 2001 by the Prime Minister of Canada, to examine broad structural issues affecting the Canadian health system. The Commission undertook an extensive program of community consultation, including: 21 open public hearings; 12 “citizens’ dialogue” sessions focussed on specific issues; hundreds of formal submissions; and 14,000 online surveys.
At the end of this process, the Commission concluded the vast majority of Canadians supported the principle that access to health care should be based on need, rather than ability to pay. The consultations also revealed strong community support for: an increased focus on primary and preventive care; additional funding for rural and remote health; and action to remove health inequalities between Indigenous and non-Indigenous Canadians.
Australia – Citizens’ Juries in WA:
These findings reflect those of a much smaller consultation process in WA in 2000 and 2001 where “Citizens Juries” were established to advise on health care principles and priorities. Members of these juries were randomly selected from the electoral role and provided with information about the health status and cost of providing services of different population groups.
The juries were then given a hypothetical budget and asked to allocate it between competing areas of health care; for example, between rural and urban services, Indigenous and non-Indigenous populations and aged and non-aged care.
The juries were able to agree on funding allocations across these areas, and placed the highest priority for spending their hypothetical budgets on providing services to Indigenous populations.
This process demonstrated that, with adequate information, citizens are both willing and able to deal with complex ethical and conceptual questions in health, and provide meaningful advice on broad issues underlying health resource allocation.
The Romanow Commission and the Citizen’s Juries project provide good examples of how the community can be involved in determining underlying principles for the health system and allocating funding across different program areas and population groups.
Centres and networks
Each region should ideally have at least one major acute facility which would act as a hub or Regional Resource Centre for other services. As well as providing a centre for secondary and tertiary level diagnosis and treatment, the Regional Resource Centre would include an education and research component to support clinical staff and to improve attraction and retention of the workforce to rural areas.
The role of acute hospitals is now focused almost entirely on a providing a very high level of diagnostic and treatment services, often supported by sophisticated technology. These services would be provided at the Regional Resource Centre while services such as minor elective surgery, chemotherapy, dialysis, allied health and outpatient services could be provided much closer to where people live, and with more community input into service planning and delivery.
This structure would facilitate the development of Rural Health Facilities to provide respite, rehabilitation, palliative care and recuperation (“step down”) care as well as a primary healthcare service, some secondary services and other population health initiatives. Provision of these types of services presents a better healthcare solution in rural areas than keeping small hospitals open, which may be unsafe due to lack of clinical throughput for the maintenance of skills and wasteful of resources through duplication.
Health services in more remote and rural areas would be more formally networked to these Rural Health Facilities and Regional Resource Centres, with specialists engaged to travel to decentralised areas and patients/clients provided with supported transport in order to move more freely between services within the area.
In addition, development of telecommunications infrastructure to support e-health/telemedicine services for both clinical and educative functions is critical to improving health services in rural and remote areas of Australia.
Additional support for treatment and care would be required from centres of excellence located in major cities utilising efficient transport mechanisms for patients needing admission.
The outcome of such a structure should be to provide services in the most appropriate setting and to minimise duplication of scarce resources.
Primary health care
Primary health care should be available to all people, regardless of where they live, their income or their health and related problems. Increasingly primary health care is being recognised as the cornerstone of modern health care and as the ‘gatekeeper’ for specialist services.
An effective primary health care system should:
- Provide early intervention through health promotion strategies;
- Focus on population groups recognising inequities in health outcomes for particular groups and targeting work with particular groups;
- Provide a seamless service (continuity of care) through strategies such as case management, care pathways, coordinated care;
- Have a holistic approach as well as dealing with the presenting health issues;
- Defer the onset of chronic disease and disability through early detection and management;
- Strengthen the consumers’ management of their own care through a consumer-centred model of service provision with a focus on education and involvement in decision-making.
Safety and quality
An emphasis on quality health outcomes is the measure of a safe health system. Economic factors should not be the primary determinant of the allocation of funds for health. However, it should be noted that, by increasing safety and reducing adverse events, the cost of care will be reduced and improved health outcomes will be achieved.
Statewide standards for quality and safety in healthcare services are necessary (preferably nation-wide). The standards should ensure:
- Sufficient funding for high level scientific research and evaluation on the measurement and improvement of patient care, health status and outcomes (including recording of adverse events), the results of which should be regularly reported including national trends and disparities in quality;
- The use of standardised information to create effective linkages between sources of health information from regional and local levels;
- Quarterly analysis and reporting of data on significant adverse events;
- Active consumer involvement and public access to an annual report of national adverse events;
- Increased resourcing for safety and quality improvement;
- Workforce reform focused on a multi-disciplinary team approach to care underpinned with education and training programs that encourage a culture of safety and greater openness in the system;
- Evidence-based practice as part of routine service delivery;
Accreditation is a way of assuring that certain standards have been met by healthcare organisations. The underpinning policy objective of accreditation is the adoption of more efficient and effective processes, leading in turn to improved outcomes and continuous maintenance of appropriate standards of care and quality improvement.
The credibility of accreditation systems depends on the expertise of both the regulatory body and those seeking accreditation. Emphasis should be on development and education rather than inspection, by providing a thorough review of all aspects of an institution's structure, systems, and processes, with particular emphasis on what patients’ experience.
Mandatory accreditation of hospitals and other health facilities should be a significant component of a safety and quality policy. Facilities should be required to provide a public report in relation to accreditation or period review.
It is recommended that all public and private hospitals should be required to adopt the Australian Council for Safety and Quality in Health Care Standard for Credentialing and Defining the Scope of Clinical Practice (authorised by all Health Ministers). This Standard provides guidelines for the organisation to verify and evaluate qualifications, experience, professional standing and other relevant professional attributes of medical practitioners and to define their scope of clinical practice within the specific organisational setting. This would allow hospital management to form a view about the competence, performance and professional suitability of the doctor to provide safe, high quality healthcare services and to delineate the extent of the practitioner’s clinical practice within the organisation.
Open disclosure is defined as “the active management of adverse events through the disclosure of timely and appropriate information” and is vital to drive and support improvements in safety and quality. A key step in the process is encouraging greater openness around adverse events. This involves acknowledging when things go wrong and providing reassurance to patients and their carers that lessons learned will help prevent their recurrence.
An open disclosure policy will promote consumer confidence in the openness and accuracy of information and should be integrated into organisational accreditation and assessment.
Implementation of a statewide health information and communications network is advised. Such a network is critical to ensuring safe care that is successfully integrated. The network would be underpinned by statewide (or National Health Performance Committee) standards (privacy, security, confidentiality of data collections and storage, messaging, classification, coding), appropriate architectures, suitable telecommunications infrastructure and incentives for providers to use the system in order to ensure secure and timely transfer of data across all sectors.
The systematic collection of public health data across the state is essential to inform health policy and planning and to monitor standards of care. Increasingly, health systems are realising that measurement and benchmarking are strategic management tools that can contribute to effective evaluation of the efficiency and effectiveness of the health system and which can drive continuous improvement.
A standardised Information Framework would incorporate indicators to measure:
- Per capita utilisation of all services regardless of setting (acute, residential, community);
- Timeliness and availability of access for each service type broken down by socio-economic status, location and ethnicity;
- Whether services are appropriate and safe (free from avoidable harm), based on standards and are responsive to patient/client needs;
- The degree of integration and coordination of services;
- Effectiveness of outcomes;
- The degree of efficiency in the use of resources;
- The level of skills and knowledge of the providing individual or agency;
- The capacity of the system to maintain a sustainable quality of care through its workforce, facilities and equipment and to be responsive to change and emerging needs; and
- The identification and qualitative assessment of emergent causal factors and trends that have the potential to compromise optimal performance.
The Framework would require all providers and agencies to create a culture of learning and evidence-based decision-making and to:
- Adopt risk management approaches;
- Report adverse incidents;
- Undergo independent review.
The National Health Performance Committee framework focuses on three key dimensions of health care delivery systems:
- The environment in which care is delivered ( structural performance);
- The way in which care is delivered ( process performance); and
- The achievements of delivered care ( outcome performance).
Mechanisms and processes to ensure a representative community voice in policy planning and implementation are critical to the successful system implementation. Such efforts in the past have often been tokenistic but the underlying value of effective consumer participation cannot be ignored.
Consumers value health care that is accessible, accountable, coordinated, comprehensive, and provides continuity of care. Groups formed by people with personal experience of the health system are now more widespread. Feelings of pain and loss can lead to the identification of others in a similar position, to the formation of organisations and action in the political sphere and to real change that improves safety and service delivery. Informal and formal alliances have formed and indicate a wider health consumer movement. Governments must recognise consumers as partners, fund representative organisations and include them as co-decision makers at all levels. This will increase opportunities for genuine consumer participation and give patients and carers opportunities to shape services in ways more responsive to their needs.
A statewide workforce planning and management strategy is recommended to support regional needs. A workforce strategy will ensure the following:
- Sufficient resources to ensure access to sustainable services and that people in areas of need or with socio-economic disadvantage are provided with equitable access. The health workforce must have the capacity to deliver safe, appropriate and quality care that is patient and consumer focused and is sensitive to all sectors of the culturally diverse and Indigenous populations on the basis of clinical need regardless of income;
- A coordinated recruitment and retention strategy (including the selection of overseas trained professionals) to address service shortfalls due to staff shortages or geographical mal-distribution. Coordination across public and private sectors is critical to ensure access to services is continuous irrespective of care setting or payer; and
- Ongoing evaluation processes that ensure strategies remain valid and that objectives are being met as measured in terms of patient outcomes.
Retention of health professionals must be addressed through providing adequate remuneration, safe hours, appropriate accommodation, access to continuing education and peer support networks. Above all, health professionals must be valued and supported by all employing healthcare organisations.
Health professionals must be appropriately educated and provided with opportunities and resources to continually improve competency levels through well-structured, ongoing vocational guidance continuing education and mentoring. This will assist professionals to work harmoniously and efficiently in multi-disciplinary teams in varying situations from acute care hospitals to community settings and to take on flexible roles in the delivery of services. Preferably, these roles should be undertaken according to competency levels rather than by professional demarcation, thus providing opportunities to overcome access problems resulting from shortages and maldistribution of health professionals.
Health sector roles
The development of complementary and supporting roles between the public, private and not-for-profit industry sectors is necessary to avoid duplication of resources, including:
- Role delineation of hospitals and other services based on their geographical locations and the needs of the population for access to elective and emergency services, preventative services, health education and health promotion; and
- Authorisation of selected private sector facilities for use by public sector providers and consumers to prevent duplication of capital infrastructure.
The Department of Health would have the opportunity to redirect resources spent on local planning, funding and administration to focus on developing state-wide policy, standards and guidelines for cross-regional infrastructure and regulatory functions as well as providing equitable funding for regions. The Department would also be responsible for evaluation of the performance of regional authorities and regional CEOs. Regional authorities should have authority and responsibility for population health and health services including the power to make decisions about service delivery.
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