Wednesday, February 25, 2009

Step Up - Step Down: sub-acute care in the ACT

The ACT is currently involved in large scale clinical redesign and health service planning to underpin an ambitious capital works program. The Capital Asset Development Program (CADP) will cost $1B over the next decade. It includes a new women and children’s hospital, neurosurgery operating rooms, refurbishment of existing community health centre and construction of one in Gungahlin and a Cancer Centre of Excellence. HCCA is involved with the health service planning and the CADP, supporting consumer representatives on high level committees holding consultations and providing consumer perspective on documentation.

This development process is seen by HCCA as an opportunity to shape our health system so that it is more consumer centred and overcome a number of longstanding problems. One such problem is inadequate provision of sub-acute care.

Sub-acute care includes rehabilitation, transition care, geriatric evaluation and management and can precede or follow hospital admission. I was pleased to see the NHHRC acknowledge the importance of sub-acute care, describing it as “the glue that connects acute care provided in hospitals with community care provided in peoples homes” (p 146 ). Their Interim Report also states that the limited provision of subacute care represents a significant missing link in the care continuum (p 146 ).

A number of our members have shared their memories of visiting relatives in convalescent hospitals after surgery or illness. This was before the closure of those facilities and the move to community based services. I think we lost something in this process and we are currently working with a group of committed consumers and carers, who consider that aspect of convalescent hospitals are needed to complement the acute services and primary care. As one consumer described it:
“It will all boil down to getting people back on their feet (as it were!) and into their homes with the minimum of trauma.”
Traditionally much attention given to sub-acute facilities has been to ease the burden of bed block. In most cases this has involved moving older patients to transitional care rather than occupying higher acuity (and costly) hospital beds. This was a driver in the establishment of a small public convalescent care unit (nine beds) in the ACT in 2002 post discharge from hospitals consumers were admitted to this unit where they are supported o regain daily living skills through personalised programs. They could stay there for up to two weeks before returning home. Sub acute care facilities such as these can improve the transition process from hospital to home and embed linkage between the acute and community sectors of our health system.

There is further consideration of sub-acute facilties on the ACT at the moment. This discussion is taking palce with regard to the Aged Care and Rehabilitation Services Plan. The plan will be released for consultation in around a month.

We would like to see further exploration of sub-acute care as an extension of primary health care, rather than acute care. The development of the “step-up” concept has been strongly supported by our members, especially those living with chronic conditions. This would enable consumer to receive a high level support in the community to keep them out of hospital. This care could be provided by multidisciplinary teams, including a range of care assistants, and there is potential to work with general practitioners to include them in their supervision of clinical practice.

The NHHRC is to be commended for their call for targets to be set by June 2010 to increase the provision of sub-acute care. This is a good opportunity for consumer movement to articulate what we need from sub-acute care so that it meets our needs for step up and step down. We think the answer lies in reframing sub-acute care as an extension of primary care rather than the traditional model tying it to hospitals.

Tuesday, February 24, 2009

Report on the Maternity Services Review

The Federal Minister for Health, Nicola Roxon, released the much awaited report into maternity services over the weekend.

The Chief Nurse and Midwifery Officer, Rosemary Bryant, led the review and this report is an important step in developing a national plan for maternity services.

The Report makes a series of recommendations in the key areas of:
1. Safety and Quality
2. Access to a Range of Models of Care
3. Inequality of Outcomes and Access
4. Information and Support for Women and their Families
5. The Maternity Workforce
6. Financing Arrangements.

The report recommends that the Australian Government give consideration to providing access to the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme to appropriately qualified and skilled midwives, working within collaborative team-based models.

This report recognises the importance of information and support for women. Without good information, women do not have options. The report does not refer to "health literacy" as such but the concept is embedded in the recommendations. The report acknowledges the critical role reliable information plays in assisting women to make decisions about their maternity care.

This is consistent with the Interim Report of the National Health and Hospitals Reform Commission which emphasises the importance of health literacy.

The report is available online as a pdf and as webpages.
Summary of recommendations is available online.

The Review Team received more than 900 submissions from consumers, health professionals, industry groups, researchers, professional organisations and national peak bodies. Submissions included women sharing their birth stories and experience of clinicians and midwives delivering maternity care, examples of existing effective models of care within Australia and internationally, and research papers on many aspects of pregnancy, birthing and postnatal care.

Interestingly, the personal stories of individual women made up 407 of the submissions received. About half of the women contributing to the Review had personally experienced homebirth. This is a much higher proportion than the proportion in the population overall. (Homebirths account for less than 1% of all births in Australia.)

In the media:
The Australian: Midwives seek access to Medicare
MIDWIVES will challenge doctors' financial monopoly over birth and pregnancy after a new government report proposed they be allowed to bill Medicare and the Pharmaceutical Benefits Scheme for their services.

The Canberra Times: Script-writing seen as new midwife role
Women will receive rebates for services provided by midwives and be able to turn to them for prescriptions if the Federal Government adopts recommendations from a report out today.

The Rural Doctors Association of Australia (RDAA) has welcomed the Report and said it provided a strong way forward for improving access to maternity services in the bush. They released a media statement.
“Families who live and work in rural and remote Australia should be able to access quality healthcare in their local communities without having to wait weeks for an appointment or having to travel hundreds of kilometres to get that care. This report offers the Government an opportunity to start making this vision a reality. RDAA commends the report and looks forward to working closely with the Minister and Government to implement its recommendations.”

The findings and recommendations of this Review will inform the development of the National Maternity Services Plan

Responses to the NHHRC Interim Report

We have been watching with interest the various responses to the Interim Report of the National Health and Hospital Reform Commission. Below are a a number of reports and links you may find of interest.

Australian Healthcare and Hospitals Association: Health Commission report hits target
"The Commission's findings reflect AHHA's longstanding concerns that years of under-funding have left Australia's hospital sector unable to meet the growing demands for care from the community," said Ms Prue Power, Executive Director, AHHA.
"We strongly support the Commission's finding that: "……hospitals are under severe pressure, directly influencing their ability to provide safe, high quality, accessible and timely care to all patients." (Pg 117)
The Australian: Experts clash over reform option merits
HEALTH experts are at loggerheads over the relative merits of the three reform options proposed for addressing concerns over hospital cost-shifting, with a top psychiatrist making a strong defence of what many see as the most radical scheme.
The Australian: Hospitals hardly rate a mention
(Opinion Piece by Fiona Armstrong, Chair, Australian Health Care Reform Alliance)
Fundamental reform of our healthcare system is long overdue, and many of the ideas put forward in the report reflect the energy and enthusiasm that has gone into advocating a shift to investing in primary health care, to provide services close to where people live, address healthcare needs in a holistic way and keep people well.
This is appropriate; the evidence for investing in comprehensive primary health care is sound, most other countries are doing it, and it's commonsense that keeping people well costs us all less in the long run. The method for funding and governing these new entities, however, is far from clear. But this is not the report's biggest failing.
That is reserved for the willingness with which the commission has reflected the ideas of those with vested interests, unreservedly accepting that the existing balance of healthcare resources (raised through taxation, private health insurance, and out-of-pocket contributions) is appropriate, even advocating that (with no justification whatsoever) that this unique "balance" must continue.
The Australian: Devil in the detail of scheme
OF all the several bold ideas contained in the interim report from the federal Government's National Health and Hospitals Reform Commission, released this week, the plan for a universal dental scheme is the one that has, perhaps, captured the public's imagination the most.
Croakey: Let citizens’ juries loose on the NHHRC recommendations (Gavin Mooney, Professor of Health Economics, University of Sydney)
The idea of the Commonwealth taking over more of primary health care makes some sense . It would make even more sense if the Commonwealth were to take over the whole ship. Patients really do not give a damn who provides their care as long as it is provided seamlessly, efficiently and humanely. The current split and what it would look like if the NHHRC proposals were implemented certainly get in the way of the first two and sometimes the last.
Having the Commonwealth taking over all care but the services run by about 20 regional authorities round the country would be a much better way to go. Apart from anything else we might then have some good public debates about what the Australian public want by way of principles and values and priorities instead of the very often distressing and unhelpful endless debates about mechanisms, who pays, who should have paid and who hasn’t got what.
AHCRA will hold a National Health Reform Summit in Melbourne on March 2-3 to discuss the NHHRC Interim Report. I will be attending for HCCA and will post to the blog after the summit. The program is available online (1.1mb Pdf).

If you wish to comment on the reform directions, you can do this in a number of ways.
Responses must be received by 16 March 2009 to allow the Commission to meet its reporting timeframe.

  • You can complete an electronic feedback survey
  • Email specific suggestions to improve the reform directions by attaching two A4 pages (1000 words) in Word format to an e-mail:
  • Write to the NHHRC no more than two A4 pages (1000 words) to:
The National Health and Hospitals Reform Commission
PO Box 685
Woden ACT 2606

HCCA will be making a further submission and we are interested in your thoughts.

Monday, February 16, 2009

A Healthier Future for all Australians - NHHRC Interim Report

It is an exciting time for those committed to strengthening our public health system. The National Health and Hospital Reform Commission today issued their Interim report, A Healthier Future for all Australians.

At 392 pages, the interim report is an impressive document. The Commission has done well to address the many issues raised in the submissions and consultations. Over the coming days (and weeks) we will continue to work through the document to identify ways in which it may influence health services in the ACT.

The Report warrants a big tick by consumers. The Commission has picked up on many of the things consumers have been saying for a long time.

In particular we are pleased to see the report comment on the importance of coordination of care between the various levels of health care. there is strong support for personal held medical records. This is very positive as it is a strategy that ensures all of the pieces of information that are important to our care are transferred and available to the personnel who are involved in decisions about our health. This will provide health professionals with a better, more complete picture and they will be better placed to make decisions that will result in safer interventions.

The Report also acknowledges the lack of resources for step up and step down facilities and other transition care services. The importance of the sub-acute care “glue” that links acute with community care is recognised. The need to enhance such programs including step-up and step-down programs is strongly supported. The report notes the variation across the country in the development of such programs and proposes increased access, improved funding, including infrastructure. This is something consumers are very keen to see extended.

We have a health system that is built in divided responsibilities between levels of government. This has resulted in disintegrated care and gaps in services which has not always serviced consumers well. The Commission is looking to strengthen primary and community based care. This move has the potential to provided integrated care and help consumers to overcome the confusing system.

The report presents the Commission’s reform agenda under four themes, which are:

  • Taking responsibility: individual and collective action to build good health and well-being – by people, families, communities, health professionals, employers and governments;
  • Connecting care: comprehensive care for people over their lifetime;
  • Facing inequities: recognise and tackle the causes and impacts of health inequities; and
  • Driving quality performance: better use of people, resources, and evolving knowledge.
Having identified these four themes the Commission discusses in more detail the elements comprising the themes and the strategies to achieve them.

There is recognition of the consumer empowerment perspective as a strategy to build healthier communities and people, which considers how individuals can take greater responsibility for their own health. This strategy is seen as relying heavily on health literacy - proposed as a component of a National Curriculum at both primary and secondary education levels. HCCA supports this positive move. Unfortunately the Report does not go on to address the imbalance of power between health professionals and health consumers –this is a critical part of the equity jigsaw. This imbalance is institutionalised and will not be addressed by better information alone. the system will need to have more strategies to enable consumers to take a stronger role in their own health care. While the establishment of citizen juries is proposed as a systematic mechanism to formulate health care priorities, the report does not seek to empower consumers through direct participation in the health care system or processes. We hope that there will be further considerations on ways in which health services can build on more consumer involvement.

Building health promotion and prevention capacity is supported but there needs to be a specific focus for individual consumers, organisations, and businesses on identified issues covering well-being, chronic conditions, self management and lifestyle issues. As part of this theme there needs to be a strong emphasis on improving health outcomes for both populations and individuals not just increased health outputs. Health services need to be linked to health outcomes.

The Interim Report is a good start and we will continue to follow the work of the Commission with great interest.