Friday, November 28, 2008

Good Medical Practice

The Australian Medical Council on behalf of all state and territory medical boards - is developing a national code of professional conduct for medical practitioners – Good Medical Practice.

Members of the working team came to meet with members of HCCA in October to discuss the draft code. we have prepared a summary of the issues raised at that discussion and have submitted this to the AMC for consideration.

Our submission is available on our website (146kb Pdf)

Monday, November 24, 2008

Comments on proposals for a national health complaints system

HCCA has lodged a submission on the Consultation Paper on Proposed arrangements for handling complaints, and dealing with performance, health and conduct matters. The development of a national complaints system is a part of the national health workforce registration and accreditation implementation. The emphasis is therefore on the development of national health profession registration boards and related performance and professional standard issues. However, the opportunity is also being taken to produce a single national health complaints system incorporating the complaints systems existing in the States and Territories. In the ACT that system is in the Human Rights Commission and headed by Mary Durkin, Health Services Commissioner. The submission which is summarised here, can be viewed in full at, raises some general issues followed by comments on the some of the specific issues and proposals raised in the Consultation Paper.
HCCA strongly supports the National Registration and Accreditation Scheme for Health Professions which should bring considerable benefits to consumers. The development of a comprehensive health complaints system as part of those national workforce proposals has the potential to provide additional benefits in terms of quality of care and patient safety.
The development of a national system for handling complaints and related performance issues will need concessions and flexibility. An unstated issue is that the system will only deal with complaints relating to individual health professionals. The broader issues of conciliation and systemic and organisational failure in public and private health care are not addressed; there is therefore a need for much of the jurisdictional complaints and health care quality and standards structure to remain and often to be enhanced. The proposal to “build on the best aspects of State and Territory schemes, rather than replicating one existing disciplinary scheme” is supported as a general principle. This does offer an important opportunity to develop a health care complaints system that provides a coordinated linked system that could enable both individual and systemic concerns to be addressed.
As a health consumer body, HCCA, wishes to see a number of principles and features included in the structure and processes of the joint national registration system. These include existing charters, standards and guidelines relating to rights and handling complaints.
The following aspects are critical in a national complaints system: consistency between jurisdictions, streamlined and transparent processes between agencies, coverage of both individual and systemic health care, easy access to the complaints system, simplify the decision making process and provide support and assistance to consumers, boards and tribunals should include a community /consumer voice and regular reporting of complaints outcomes to health authorities and the public.
From the health consumers’ point of view the actual complaint structure is not the critical issue. The issue is the service provided within that structure, which must be responsive to the concerns of consumers, result in improved health outcomes, be free of both professional and bureaucratic conflicts of interest, have a seamless flow of information with other relevant bodies, be transparent, communicate well and be timely in its decision making.
The national complaints system, together with State and Territory systems, has the potential to provide an invaluable national database on a number of aspects of the operation of the Australian healthcare system. These data could provide current, reliable, validated, national information on the safety and quality issues as well as the national health workforce. This data should be reported both to health authorities and made available publicly.
Roles of national and jurisdictional complaints bodies
The Consultation Paper’s lack of clarity in defining the respective roles of the jurisdictional Health Complaints Commissioners (HCCs) and their relationships with the boards is regarded as a major issue. The Paper notes the value of the HCCs and comments that the “contribution of health care complaints bodies to the maintenance and improvement of health services is important and valuable” However, the it then goes on to suggest that the HCC role should simply be that of conciliation. It appears that the new system based on the boards is to address shortcomings of individual, not those due to systemic or organisational failure. ACT health consumers would be concerned if the role of the ACT Health Services Commissioner was reduced to a conciliation role. Currently the ACT Commissioner is able to initiate independent reviews and investigate systemic issues. While accepting the need for coordinated action and consultation with appropriate boards it is important that the Commissioner retain this role.
The lack of clarity does also result in the potential for complex and unresolved complaints “falling into cracks” or the resolution being paralysed.
A keystone of the current ACT health complaints system is its independence from the health bureaucracy and the health registration boards. HCCA sees this independence as an important issue in giving assurance to consumers that the complaint resolution mechanism is independent from the health care professions and the health arm of government.
The ACT experience is that while the contribution from conciliation is important, the wider contribution by investigation of professional competence and standards and systemic issues are also critical contributions. Certainly in the ACT the HCC has developed a reputation for independence and impartiality. If the boards are designated as the only recipients of complaints regarding professional competence there needs to be a careful explanation to consumers and consumer bodies about the rationale, processes and safeguards.
The Consultation paper is available at Further consultation, including national and State based forums will be held in March 2009. Further consumer input is therefore very welcome.

Tuesday, November 18, 2008

Blood culture to change, but not at any price

Russell McGowan recently attended a national seminar, run by the National Blood Authority in Sydney. He has written the following post on a few issues that emerged.

I learnt that blood is not actually free, but comes at a price. That price can be up to $1000 per unit of fresh red cells transfused, and more like $2500 per patient assisted. In fact, the cost of blood accounts for as much as 5% of all health expenditure.Now I have been a frequent user of blood and blood products in the past – at one stage receiving as many as six units a month as my enlarging spleen started to consume all the blood my bone marrow could produce.

Subsequently, I became a heavy user of IVIG, a fractionated derivative of blood plasma, to boost my immune system following my bone marrow transplant. As a result I have followed the evolution of blood service arrangements in this country with some interest. The latest development is that private hospitals in NSW are to be charged for the blood that they use. (see article from The Age, 15 November 2008).

This will be seen by some as exploitation of donors (including my daughters) who give blood freely to help the health system do its job. Fortunately I won’t have to refund the health system for all the blood I have received over the years, but what will it mean for other consumers?Why would a State Government break ranks with its counterparts and start charging for blood? The answer is quite simple – we don’t value what we don’t have to pay for.

Blood is often used inappropriately in health care when other therapies would be more cost effective and probably would produce better outcomes for consumers. So at a time when threats to the blood supply are looming larger than ever before, it makes a lot of sense to set some price signals to help control use of a scarce resource.Surgeons can operate successfully without resorting to blood transfusions – they do it already for Jehova’s Witness patients. Haematologists can learn not to resort to transfusions for anaemia when mere infusion of intravenous iron can achieve an equivalent or better effect.

In the ACT, the TCH blood team has recently attacked wastage of blood in operating theatres where excess units are provided for surgery just in case they are needed, but are left lying around at room temperature for too long in the process and then need to be discarded rather than being used elsewhere. A good start to dealing with an insidious inefficiency.

I am more than happy to discuss these issues with any readers interested in them. In addition there is an opportunity for consumer input to a professional and community forum being conducted by the National Blood Authority here in Canberra in early December.It is to be hoped that blood culture can be changed in the health system to ensure better outcomes for consumers and that politics generated the NSW Government action will not railroad reforms into a dead end siding.

Russell McGowan

Monday, November 17, 2008

Maternity Services Review - Round Table on Workforce

National Maternity Services Review
Round Table Forum on Workforce Standards, Quality and Inter-Professional Collaboration

The Government is undertaking a Review of Maternity Services. I have posted on this already. The Review is led by the Commonwealth Chief Nurse and Midwifery Officer, Ms Rosemary Bryant.

Maternity services in Australia are in need of change. While we generally have safe services there is still room for improvement. This need has been recognised and there have been several inquiries into maternity services in Australian states and territories where consumers have provided feedback. The current review will (I hope) build on previous work to develop a national maternity services plan.

In October I attended a Round Table Forum on workforce issues. The Forum brought together over thirty people including academic and professional leaders in maternity services, representatives from unions (Nursing Federation and the AMA), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and two consumer representatives.

The discussion was structured around three questions:
  • What are the key professional development needs, including interdisciplinary, of the maternity workforce?
  • How will models of workforce vary in rural and urban settings?
  • Where are the key workforce barriers to integrated models of care?

There are significant issues regarding the maternity services and rural and remote communities. There was consensus that high quality care can be provided in rural and remote areas through outreach services.

The issue of culturally appropriate / sensitive services for women was raised. Indigenous women report not feeling safe in the care of the services and are reluctant to attend. There is a need to further consider the needs of a range other other culturally and linguistically diverse women. Put simply: if women do not trust the services they are not going to use them. The potential for poor outcomes in terms of perinatal and maternal deaths is considerable.

There is pressure on the number of training positions. The Department of Health and Ageing are funding a series of training positions for medical trainees in private settings. There was discussion about the degree to which private obstetric practice can provide these additional training places.

There has been a lapse in the communication between the College of Nursing and Midwives and the College of Obstetricians and Gynaecologists which they hope to rebuild. This can only be a positive move for consumers.

There are many workforce issues around maternity services, including training and shortages, and there has been considerable discussion whether the existing workforce is able to service the existing demand. There is a challenge of balancing workforce issues regarding roles, training and funding with the need to provide more continuity of care for women, and at the same time rationalising of services to fit within the health budget. The “turf” war between medical specialists and midwives places further pressure on the system to plan for and deliver safe and quality maternity services. These tensions and challenges influence the way in which reform of maternity services is framed. There is no better time to re-frame maternity services from a consumer perspective.

I do have some concerns around the level of consumer participation in the review. Representatives at Round Tables such as this goes some way but we need to work with the Department to have more meaningful engagement if we are to develop a national maternity service plan that reflects the needs of women and our babies.

Darlene Cox
(wearing my CHF Consumer Representative hat)

Wednesday, November 12, 2008

AMA Report Card on Public Hospitals

There has been considerable interest in the recently released report from the AMA on the state of public hospitals. Their report, Public Hospital Report Card (2008) is available on their website 708kb Pdf. The AMA have recognised that our public hospitals are under pressure and are calling for an immediate $3 billion injection of federal funds.

This has had coverage in major newspapers including the Sydney Morning Herald and the Canberra Times.

The AMA is quite right to draw attention to the bottlenecks occurring in Australian hospitals, but it is a bit behind the game. At the national level the Commonwealth has established a Health and Hospitals Reform Commission to address these problems, and locally the ACT Government is implementing a major capital asset redevelopment plan covering both TCH and Calvary Hospitals

Consumers will welcome additional beds which ensure that they are not caught up for long stays on trolleys in emergency departments when they need to be admitted, but we have been saying for some time that many of the new beds needed could be lower acuity beds at step down facilities, enabling convalescing patients to be discharged earlier form the acute care hospitals.

If the AMA really wants to ensure that taxpayers get best value for our health dollar, they will also be advocating for health care to be provided in the most appropriate setting, which means more primary health care and preventative services, and not just more acute care beds.

Monday, November 10, 2008

HCCA 2009-10 health budget priorities

HCCA input to ACTCOSS submission for 2009 - 2010 ACT Health Budget
HCCA views and priorities for 2009-2010 reflect a continuation of those proposed last year. While supporting the outlays proposed through the Capital Assets Development Program, HCCA argues that these additional capital assets and infrastructure must be seen as a means to providing the necessary services.
It is also important to ensure that the immediate service needs are met at the same time as the investment in the medium to long term infrastructure is taking place – there must be balance.

Identified Priority Areas - which warrant increased resources and policy emphasis

Primary health care

  • Ensure supply of GPs and nurses to ACT through recruitment and training programs
  • Restructuring of health workforce eg nurse practitioners and allied health assistants
  • Chronic condition management, including support for self-management
  • Community health centres/clinics (Walk-in/Super GP clinics)• Community based services – including allied health services and support
  • Health promotion and illness reduction

Aged and palliative care

  • Develop appropriate housing/residential needs
  • Develop transition facilities/services including convalescence beds
  • Expanded respite care
  • South side hospice
  • Palliative care services and community based services
  • ACT based spinal injury rehabilitation centre and services
  • Improve access to HACC programs and services for residents of aged care facilities

Community infrastructure and supportive care programs

  • Enhancement of aged care services inc equipment loan scheme
  • Dental health
  • NGO support networks

Mental health

Consumer participation in ACT Health

  • Need additional training resources and support to meet increased demand for consumer representatives from government
  • E-health (electronic information, digitised images, individual health) will require more informed consumer representatives and improved consumer health literacy
  • Develop consumer advocates and system “navigators”

Cancer services

Maternity care

Monday, November 3, 2008

Consultations on aged care and rehabilitation issues paper

Outcomes of the Aged Care and Rehabilitation Issues Paper/Options Consultation

Health Care Consumers Association of the ACT Round Table on 20 October 2008 at HCCA office Pearce Community Centre

There was a broad discussion on the underpinnings of the ACT aged care and rehabilitation services, the purpose of the plan, its context, its relationship with other health and broader government plans, coordination mechanisms and the need for monitoring and evaluation. It was throught that a preamble to the Plan should be provided to reflect those broad issues.

  • Development of specific care coordinators that look at the person as a whole – social, housing, physical health. These care coordinators must be able to cross all ACT Government Departments
  • ACT Health to develop an appropriate convalescent facility (not a sub-acute ward) that allows people to appropriately transition back to their own home and or their new living arrangements
  • Develop a spinal rehabilitation unit within the ACT
  • Increased numbers and role for Nurse Practitioners
  • Development of a single HACC funding service
  • Increased palliative care services in the ACT (new facility constructed on the south side). Services should also be able to be accessed in facilities, home or community.

Consumers at the forum also raised the following more specific aspects and issues to be considered in preparing an aged care and rehabilitation services plan.

Scope of Plan
  • The Plan needs to be realistic in terms of the planning period and resources
  • The Plan should be defined in relation to the type and range of services being incorporated in the Plan against the broader context of the other available services; public/private: ACT Health/Commonwealth: ACT/NSW needs and services: aged care services/ community based/acute care/aged residential.
  • The scoping of the Plan must also address both existing financial/funding models and those proposed.
  • How does this Plan fit within the Capital Asset Development Program and broader ACT Government uses for other assets such as closed school sites?

Planning process
  • The planning should take as its starting point existing services and structures, identification of shortcomings and positives
  • Plan should include an implementation strategy and process
  • Plan must be able to proactively interact with other Government agencies eg on local housing issues
  • Plan to identify key performance indicators for monitoring and evaluation; this requires incorporation of appropriate data collection from the start of the Plan (preferably with a starting point baseline)
  • Plan to be evaluated some 12 months prior to end of planning period.

Service philosophy

Plan must look at the person as a whole and must
  • be person centred
  • take into account the social needs of the person (not just physical)
  • take into account the housing options
Plan to incorporate the community location approach rather than locating services adjacent to hospital campus.
Plan to provide for transition facilities and support services such as step down and convalescent facilities.

Identification of needs and issues
Demography including:
  • current and projected demand based on demographic and service data
  • comprehensive data-base of current services and user outcomes
  • existing policies and plans
  • outputs, findings and recommendations from recent and current reviews eg Equipment Loan Scheme
· Identify service gaps, transitions and services
· Consult with consumers, carers, health professionals.

Service Coordination
Discontinuities between the aged care facilities and hospitals are large
Gaps lead to huge personal impact and financial impact for the individual
and the need to support families and carers
There is a distinct lack of flexibility in service providers
Need for transition facilities and services
There needs to be specific care coordinators (see ACT Government Coordination across departments below)
- a navigator model
- cost effective
- may also need to act as an advocate
Plan should outline strategies to enable proactive linkages with other ACT Government Services:
  • must be a whole of government approach that has all departments working together
  • some people don’t want services that are run by non government organisations
  • no out-sourcing of services traditionally provided by ACT health or ACT Government
  • Northside Community Service ‘burnt’ 80k and provided a very poor service
  • There are many services provided by non ACT Health service providers andhow will the plan link to other non government service providers
  • Consider a single phone number to call to ask advice and or to help

Transition services
· There is an Australian Government push to centralise access to community care – this seems counterintuitive
· Identified a preference for government service (see Northside issue)
· There is need to simplify funding and services (i.e. broader entry criteria?)

· Convalescence beds are a critical service that needs to be reinstated
- enables an appropriate level of care
- allows for the individual to practice being at home
- there were 9 beds
- sub acute beds are not appropriate
- this should not take to form of a medi-hotel
- staff must be appropriately trained – i.e. not just certificate IV workers
· Clients who require a nursing home placement but are in the hospital system
- Needs are different from a convalescent facility
- There needs to be transition facility to free up the acute bed and provide the appropriate level of care for the individual
- Currently they are scattered throughout the hospital
- They should all be accommodated in one ward (or facility)
- There are between 20 and 25 people in the predicament
· Step down facility should be investigated as integral part of this service..

· Appropriate housing is a key
- Policy regarding single person single bedroom is poor
- Does not allow for visiting carer
- Can therefore lead to increased hospitalisation
- There is much time spent finding housing for those in need
- This costs far more than modifying housing
- i.e. $1200 per day for a hospital bed versus $20,000 for modifications, equipment and services for a year
- ACT Housing houses must be built with ‘universal design’ (adaptable housing standard AS 4299) at its core
· The Plan must enable ACT Health to engage to achieve a change in the attitude of ACT Housing
- People must have the ability/power to make decisions
- Allow some people to have modification made to their houses early
- Environmental sustainability must play a role also
- All departments must report against this

Identified needs
  • Spinal injury rehabilitation: Plan should incorporate the processes needed to establish a case for ACT based specialised spinal injury and acquired brain injury units that can provide the necessary rehabilitation. Currently acute care is done well at TCH but spinal injury rehab is done in Sydney, which is disruptive stressful and expensive
  • Inability to access an appropriate equipment (loan) scheme
  • Are ‘not wanted’ by NSW health system

Palliative Care
- There will be an increase in palliative care services
- There needs to be a hospice provided on the south side
- The government should set aside land for this now and provide capital for its construction
- People want choice in services and options:
§ Community based (specific hospice)
§ Hospital based
§ Home based, with appropriate services provided to the home
- What are the projections for palliative care?
- Anecdotal evidence suggest that Calvary are not keen for a second hospice
§ Felt that there was very little accountability in the services they provided
- The group was not aware of the turn away statistics but felt that, from their experience, they were likely to be high
- COTA did some research ~ 20 years ago
§ Majority wanted palliative care in the home
· If they had a carer
· If the carer could cope
· If they were not in pain
- There is a respite service available
§ 2 beds only
§ Needs to be enlarged
§ Booked out well in advance
- Look at best practice palliative care strategies from around the world
- Review ACT strategy

Workforce issues
· General Practice
- hard to get GPs in Canberra
- almost impossible to get a GP to go to an aged care facility
§ it is expensive and difficult for them to do
§ when they are at the facility they often get inappropriate referrals (from untrained staff)
· Aged care nursing
- an issue both in aged care facilities and community care
- increased use of nurse practitioners

· Allied health care
- lack of occupational therapists is a particular issue

· How do we use workforce better
§ E.g. OT are unable to achieve the results the could because they cant access services and are doing too much administration
· Aged Care facility workforce
§ Not valued
§ Under paid – nurses are paid ~30% less than ACT health nurses
§ Under trained – many have a Certificate IV, many do not
· Community nursing
§ Highly valued
§ Must be funded
· Some OH&S requirements are silly
§ Using lifting equipment that takes one person in a home requires two people in hospital and or nursing home
§ This can prevent and delay the delivery of essential services
§ Risk framework needs to be looked at and appropriately managed

Aged care residential facilities
· Concerns
- once a client goes into the facility they lose their rights to choice
§ The facility knows what is best for them
§ Cant (always) access HACC services
§ Cant access community transport
§ Often lose the access to the community which increases social isolation that leads to further problems
- Care coordination would be appropriate
§ Facilities may chose not to be involved
§ This would leave their clients out of the loop
- What can be done to influence aged care facilities
- Recognise that many facilities are no longer profitable
§ Many more high care clients than before
§ Churches are now getting out of aged care
§ Maybe there needs to be a change in the model of care
- Is it appropriate for aged care facilities to look after older ‘high care’ clients?
- Staffing in aged care facilities
§ Under trained
§ No nurses
§ Not valued as employees – paid less than ‘someone packing shelves’
- Young people in nursing homes
§ This is in appropriate

- Two tiered system does not work well
- Too many different sources of funding
- Funding is too “specific” – too many criteria that makes it difficult to get funding and then to report on it
- ACT needs to try and influence Australian Government to simplify the system
- Would like to see HACC territory based rather than Australian Government
- Which department should administer HACC?
Other issues
· Refer to consumers and carers separately

· Social sustainability
- Key to keeping fit and healthy
- Remain connected with their community, their friends and their family

· Finance
- Against a brokerage model
§ Felt that this was just anther source of losing money
§ Need to review models that support the community sector

· Chronic Care
- Coordinated approach
- Self-care or self management
- Provide for greater levels of care

The Plan should include an implementation plan with appropriate strategies and a schedule – noting the earlier comment about the need for measurable key performance indicators.