Thursday, May 29, 2008

Primary Health Care

I subscribe to and have been following a new discussion on primary health care. We hope that these ideas are ebing fed into the National Helath and Hostprials eform commission. Of particluar interest is Associate Professor Simon Willcock, who works as a GP in Sydney has commented on primary health care. He says:

There have been some positive changes in recent years, aimed at rewarding quality of care rather than patient throughput, a significant part of my practice hasn't been particularly helped by the current Extended Primary Care items.

This group often has complex medical needs, Homeless and unemployed individuals, people with chronic psychological health or substance abuse problems, and isolated young people whose needs were largely ignored by the previous government can't have their needs met without a comprehensive reassessment of how we provide care and support to these groups.

They are often mired in a morass of bureaucracy, bounced from Centrelink to Medicare to the Department of Housing to the desperately under-resourced state health outpatient services.

Fiona Armstrong, Convenor of Australian Health Care Reform Alliance, has responded to Simon Willcock’s concerns. She writes:

Simon Willcock’s concerns echo those of many in lamenting the inequitable access to services under our current models of primary health care. The current system of primary health care funding in Australia creates serious barriers to people whose personal resources affect their ability to fund out of pocket costs for services that are not bulkbilled.

Australians are facing increasing out of pocket costs health care costs and an increasing number are failing to seek essential health care because they can’t afford it.

An international comparison of health care by the Commonwealth Fund (USA) has revealed that in recent years 34% of Australians have either not filled a prescription, had a health problem but didn’t see a doctor, or failed to complete a recommended medical test, treatment or follow-up, because of cost. And 43% of people in Australia from below average income groups could not afford dental care. Australia ranked fourth out of the six countries surveyed in these measures of access to care. It is a disgrace in a country as wealthy as ours, with a supposed universal health care system, that people are unable to access essential health care.

One of the essential principles of health care in a modern democracy is that access to health care is a right, and should be available on the basis of need, not the ability to pay. The current system of primary health care funding in Australia however creates serious barriers to effective health promotion and chronic disease management, and is limiting its effectiveness in terms of equity, access and value for money. Major reform is needed.

The current system in Australia of primary health care is more appropriately described as primary care – familiar to most Australians as a trip to the GP. More often than not, primary care in Australia (as researcher Helen Keleher describes): “involves a single service or intermittent management of a person’s specific illness or disease condition in a service that is typically contained to a time-limited appointment”. However primary health care, as identified in the international Treaty of Alma Ata, is characterised by a focus on the promotion of health and the prevention of illness, according to principles of equity, access, and community empowerment, and achieved by care delivered by multidisciplinary teams.

An example of a more effective model of primary health care, for both people using the services and the professionals providing the services, is that of primary health organisations (PHO) in New Zealand, where salaried health professionals offer well integrated multidisciplinary patient centred care to an enrolled population. People using the services are able to have comprehensive health care needs met by the most appropriate health professional, and health professionals have the benefits of working in a collaborative environment with support from their multidisciplinary colleagues and the satisfaction of working in a team to share the care of the community they provide services to.

Evidence suggests that this model is not only more cost effective than fee-for-service models, where costs blow out in an uncapped system, but it provides for the delivery of high quality best practice care, as it offers greater scope for better utilisation of available skills and the ability to provide services that are responsive to community needs.

A centre such as the NZ model employing a range of health care professionals – nurses, doctors, allied health professionals, counsellors, dieticians, and psychologists - can also provide a much more holistic and effective form of primary health care than a solo GP.

A mechanism for funding this, as in NZ, could be a population based capitation as a mechanism for improving access to, and coordination of, primary health care services in Australia. This is something the health reform commission, in its charter to “improve frontline care”, would do well to consider.

Fiona Armstrong, Federal Professional Officer
Australian Nursing Federation

Friday, May 23, 2008

Keeping young people connected with mobile phones

As I posted earlier this week, I went to a fabulous conference in Brisbane about how non profit organisations can use social media. By social media I mean blogs, instant messaging, social networking sites like Facebook (you can find me there) and a host of others.

I attended many sessions. One session that really stayed with me was on a collaborative business partnership between Vodaphone Australia, Mission Australia, Barnados and Youth off the Streets. The Young People Connected program provides handsets to disadvantaged youth
who are involved with these community services. The mobile phones are a great tool for increasing independence to young people. This project won the Australian Community ICT Award for 2008 for best use of telecommunications in a non-profit setting.

There are assumptions around the digital capacity of young people. We live in a world of digital natives and digital migrants. We are aware of the digital divide and we usually we associated this with older people. Assumptions are made about the skills of young people regarding technology. We assume that because they are young and the communication technologies have existed all their lives, they are skilled users. However this may not be the case. We have the expectation that young people will be digital natives but many, through circumstance, are digital poor.

This program is working to make a difference to young people who are disadvantaged and at risk and to the organisations that support them. The mobile phones have a free call facility to fifteen services such as Lifeline, accommodation services and their case manager. The user can make these calls regardless of the credit. Service staff have access to a web-based text messaging service which they use to send reminders to clients, suggestions of what to do, instructions and guidance as well as sending broadcast messages. They also send messages to let them know that someone is thinking of them or to say happy birthday.

These young people may be in the situation for many reasons: lack of education, employment, health issues, geographic location, and family function. These young people are most at risk when they are disconnected from support networks. The young people are able to connect with others, access support and realise a level of independence through the use of these phones. The benefits young people have reported to this team include: better social connections through improved family and peer relationships, increased opportunity for employment and then the follow on improvements for income and health status.

The mobile is a significant icon of modern life. It keeps people connected, they are easy to obtain and you do not need to go through the bureaucratic processes involved with securing a landline. They move around with you and keep people connected through a number of modes: text, conversation, images, video and voice messaging. You are ‘somebody’ with a mobile phone. You are contactable and able to connect with others.

Tuesday, May 20, 2008

Connecting Up

I'm in Brisbane for a couple of days at a conference on social media and not for profits. It's called Connecting Up 2008. It has been very affirming to see other organisations make the leap of faith and embrace this technology.

There is a great connection for HCCA and social media. To be effective in using social media and networking tools we need to build relationships, build networks and communities and understand the needs of our audience. This is everything that we are trying to achieve in the consumer advocacy world.

I have been truly inspired to meet Beth Kanter. Beth is engaging, knowledgeable and enthusiastic in leading non profit organisations into the world of social media. I think I have finally met someone who has harnessed her passion for change.

I've also made links with a range of people interested in the things I am doing with my local P&C, trying to engage parents in discussions around policies and sharing experiences. And I have spoken with a number of representatives from self help groups and consumer groups about their moves to blogging.

I am very excited at the prospects that this technology holds for active citizens and I look forward to sharing this with you.

Wednesday, May 14, 2008

Universal Heath Care

Universal health care is health care coverage which is extended to all citizens.

The Medicare website proudly announces:

Welcome to Medicare - Australia’s universal health care system. Medicare ensures that all Australians have access to free or low-cost medical, optometrical and hospital care while being free to choose private health services and in special circumstances allied health services.

Universal Health care is back in the media. The National Health and Hospitals Reform Commission (NHHRC) is talking about universal health care. The Prime Minister has been quoted as saying that Australia's 40-year-old universal healthcare system is failing to deal with new developments, most notably in mental health and dental care. There is some suggestion that the NHHRC is considering enhancing the Australian Health Care Agreements to reflect the whole health needs of the person, including mental and dental health. There is also significant international discussion on universal health care.

There is an issue of how we can fund this. As consumers we understand that the public purse is limited and Medicare can only provide so much, and we have moved beyond a publicly funded universal health coverage. Instead we have a health system that is delivered through a mix of public and private funding arrangements, including out of pocket payments by individual consumers. The services are provides by the Commonwealth, states and territories, non government organisations and private providers.

The Commonwealth Fund has an article on how to achieve universal health coverage while lowering health spending. They present an overview of a new health reform framework, built on the current U.S. mixed private–public system that "provides a pathway to universal coverage with a minimal increase in total national spending and relatively modest net federal budget costs." There is a range of views posted in the comments to this article that demonstrate the difficulties in meeting the needs of all.

The Commonwealth Fund also draws attention to changes in the Netherlands, with the launch of a sweeping national health care initiative in 2006 to provide universal health care coverage for its population. The Health Insurance Act 2006 requires all people who legally live or work in the Netherlands to buy health insurance from a private insurance company. Consumer can choose from 14 insurers.

The Commonwealth Fund says that this model “succeeds in providing quality insurance coverage, at affordable cost, to nearly all its citizens--while continuing to have private insurers play a leading role."

We are not alone in trying to provide health services for all citizens and find the right combination of public, private and NGO providers.

Thursday, May 8, 2008

Beyond the Blame Game

The National Health & Hospitals Reform Commission has posted its first report on the Australian Health Care Agreements (AHCAs). The report is called Beyond the Blame Game: Accountability and performance benchmarks for the next Australian Health Care Agreements

The NHHRC is looking to overcome ‘the blame game’ traditionally associated with the (AHCAs) to improve patient care.

In brief the NHHRC report suggests that the scope of the next generation AHCAs will be broader than hospitals. This report has a strong focus on accountability. The NHHRC are considering a shift in responsibility. They propose:

  • States to be accountable for public hospitals, mental health, maternal and child health and public health,
  • the Commonwealth to be accountable for primary care, prevention, aged care and indigenous health.

This assignment of responsibilities does not necessarily imply an immediate transfer of functions: states will continue to have an important role in service delivery in areas where we have suggested the Commonwealth exercise greater policy leadership with corresponding accountability

The proposed accountability framework comprises 44 benchmarks where performance against a target should have a clear and usually financial consequence. The Executive Summary says that

the most significant of these criteria in terms of transforming the AHCAs are: the need to move towards a single level of accountability for the effective use of benchmarks; the importance of reciprocal accountabilities and benchmarks on all governments; and the need for benchmarks to be set at levels that encourage real improvement.
In addition to this the report highlights twelve health and health care challenges that must be addressed in the AHCAs to enhance health promotion and wellness and to make the health system work better for the people who need it and use it.

The twelve challenges are:

  1. Closing the gap in Indigenous health status,
  2. Investing in prevention,
  3. Ensuring a healthy start,
  4. Redesigning care for those with chronic and complex conditions,
  5. Recognising the health needs of the whole person,
  6. Ensuring timely hospital process,
  7. Caring for and respecting the needs of people at the end of life,
  8. Promoting improved safety and quality of health care,
  9. Improving distribution and equitable access to services,
  10. Ensuring access on the basis of need, not ability to pay,
  11. Improving and connecting information to support high quality care, and
  12. Ensuring enough, well-trained health professionals and promoting research.
You may notice that some of these issues were raised in the 2020 Summit. An overview of the Summit is in the current issue of Consumer Bites.

Wednesday, May 7, 2008

HCCA Response to ACT Health Budget

The ACT Government’s 2008-2009 Health Budget deserves support for responding to a broad range of need identified in the health system with a series of worthwhile capital and recurrent funding initiatives.

In the context of the ACT Governments’ undertaking to grow health services provision ahead of CPI increases it is appropriate that recurrent outlays for public health services will increase in real terms by 8% from an estimated $641.6m in 2007/08 to $693.5m in 2008/09.

In particular, commitment to providing an enhanced intensive care (ICU)/ high dependency unit (HDU) at Calvary for better coronary care and opening more beds and a surgical assessment and planning unit at TCH, are to be welcomed. The construction and provisioning for a dedicated operating theatre for neurosurgery should also be welcomed as it should enable safer and higher quality outcomes for neurosurgery patients. There remains a need to develop additional cancer services and integrate existing ones better within a comprehensive Canberra Cancer Centre, but I guess we might have to wait the outcomes of feasibility planning of the overall health facilities at the TCH site before seeking budget commitment to that.

Much more significant in this budget in dollar terms is the $300m commitment towards revamping our public health facilities in the Territory, especially at the two public hospital sites. However, potentially even more significant in the context of necessary health service reforms are the new community health centre in Gungahlin and promised nurse practitioner led walk-in primary health care centres in both the northern and southern suburbs. The current estimate for the full capital upgrade of the ACT’s public health facilities is thought to be of the order of $1B. We shall see if that full amount is forthcoming over coming years and whether it is enough.

This planning for capital works is timely and will position the ACT to meet anticipated increases in demand for services which are expected to peak in 8 to 10 years time. A consolidated women and children’s precinct at the TCH site makes sense, and can easily be progressed while planning for the rest of the site and the long awaited psychiatric services units at Woden now seem almost tangible at last. All of this capital asset development needs to go hand in hand with flexible clinical services planning that reflects changes in capital asset needs when models of care or health technologies change.

Digitising image capture used in breast cancer screening is also a welcome initiative, in this budget, but is only one of many e-health initiatives needed to bring our health system into the modern IT/ information management age. There may well be scope for doing more in this area with some of the capital works development and fast tracking funds provided in this budget, but consumers will be wanting to see that these IM/IT problems are not overlooked or placed in the too hard basket. Most of the remaining money will be needed for feasibility planning for new single bed wards and better integrated surgical and imaging services in a new building at TCH and we look forward to that being achieved with minimum disruption to those who will have to continue to use the site during the construction phase..

But all this spending on physical and other supportive infrastructure will amount to very little in terms of better outcomes for healthcare consumers unless there are concurrent reforms of the ways in which health care services are delivered,

In particular, the health system in the ACT, like many others, is facing serious challenges like the need for structural reform of health service delivery modes (both for models and locations of care) and in the recruitment and retention of qualified staff in areas of need. Also the relationship between government provided services and those provided in the community and private sectors will need to be re-examined to ensure that inequities in access are not being systematically entrenched. More funds will also need to be directed to community health literacy and maintenance of wellbeing rather than just providing episodic treatment for periods of illness arising from chronic conditions and acute illness or injury. These areas will all need further attention in future budgets.

It is hoped that between now and the end of the year that there will be further Commonwealth funds earmarked through the Health Care Agreements for structural reform of the models of care which impact most on health outcomes for ACT consumers. These agreements need to be extended to cover more population health and illness prevention measures, as well as better provision of supportive care for the frail aged in community and specific aged care settings rather than just consigning them to hospital beds when their health care needs become too challenging.

Remember that the outcomes consumers are looking for are not just impressive health care facilities or mere increases in life expectancy, but also improvements in the quality of our lives and the quality of care we receive. It’s the personal experiences of consumers and our health outcomes that ultimately measure the success of any health system. This mans reformers will need to focus on the access and affordability dimensions of quality and not just the efficiency dimension beloved of bureaucrats and governments or the convenience and reward dimensions seemingly focussed on by some health care providers.

Russell McGowan

7 May 2008

ACT Budget - what does it mean for health consumers?

Last night I went to ACTCOSS to consider the budget in terms of health services. What follows is an overview of what I discovered.

Finally we start to get some details around the Capital Asset Development Program (CADP). The ACT Government 'Building the Future' program has allocated $300 million for the first stage of what we believe will be a $1 billion redevelopment of ACT health facilities. This will include:

  • $90 m – a women and children's hospital on the site of The Canberra Hospital
  • $23.6 m – an adult mental health acute in-patient unit on the Woden site
  • $18 m – a new community health centre at Gungahlin
  • $9.4 m - 16 new beds ICU/HDU/CCU facility at Calvary Hospital
  • $2.4 m - 24 additional beds at the Canberra Hospital
  • $5 - redevelopment of community health centres

The ACT Government commitment to infrastructure needs to be supported. It demonstrates that they are planning for the future rather than only reacting to immediate events. We know that there has been significant work within ACT Health in projecting future needs of the community. Admissions to hospital are increasing annually and with the aging of the baby boomers planners are anticipating a peak in demand for services 2016. This budget is a starting point.

It is essential that these infrastructure developments are progressed hand in hand with the health service planning that ACT Health is engaged in. There needs to be flexibility built into the design of buildings to accommodate changes in practice that lead to improvements in services.

Last September, when HCCA submitted our priorities for the ACT Budget we identified access to primary care as the most important. Interestingly, the scoping study for Primary Care Walk-In Centres is the only initiative that directly relates to primary care in this budget. This may involve enhanced nursing roles, such as nurse practitioners. There is an overwhelming need within the ACT to address access issues to primary health care. There is a direct relationship between access to GPs and presentation rates at the ED. We need to consider expansions of roles of a range of health professionals and the use of nurse practitioners, physician assistants and the role of the practice nurse. This may be addressed to some degree in the Workforce Initiatives. The GP work in Canberra Campaign will hopefully result in increased numbers of GPs more accessible services for consumers. I hope, with the rescoping of the Australian Health Care Agreements, primary care will complement our local public health services.

There appears to be a gap in terms of dental services in this budget. ACT Health has improved waiting times; for example, the waiting time for those consumers accessing non-emergency dental services has decreased from an average of 16 months to 10 months. And those consumers who are eligible and have an urgent need are seen within 24 hours. There was scope to fund an adjustment to the eligibility criteria to accommodate many of the people who are currently ineligible and who are unable to access private dental services because the cost is prohibitive.

There is a focus on providing ‘more beds’ but this is not just the solution. We would like to see emphasis on doing things differently, developing innovative models of care across a range of settings, expanding the roles of health professionals to move away from the default position of supplying services in the acute setting.

In summary, a good starting point. Russell will provide further insight with his analysis of the budget.

I look forward to the dialogue with ACT Health about how consumers cna be engaged in shaping these initiatives.

Darlene Cox
Executive Director