ACT Budget 2017 - HCCA Initial Response

During the election campaign in 2016 Health featured strongly. The ACT Labor released a range of election commitments as part of their Ten Year Health Plan. This included significant infrastructure investment with the design and construction of the SPIRE centre, a new, expanded emergency department, an extension of the women and children’s hospital, more walk in centres and funding for a new building for Winnunga Nimmityjah Aboriginal Health Service. This budget starts to bring this vision into reality.

People will notice that there are delays in the state of many of the commitments, such as SPIRE, and these will not see services delivered before 2020. This is for a number of reasons.

ACT Health has started a process of planning for health services for the next ten years. This process is called theTerritory Wide Health Services Plan. This will include the development of models of care (the way care is delivered) as well as looking at planning for the workforce we will need to deliver the care. Technology – through the Digital Health Strategy – will also be considered. And all of these feed into the design of the new buildings. To bring the infrastructure projects forward without doing this planning is putting the cart before the horse. That is not to say the system is working well currently.

We know that there are significant pressure on our public hospital system. Canberra Hospital is one of the busiest Emergency Departments in the country. Calvary continues to experience increase in the number of people presenting there. And the Outpatients Departments are busier than ever.

There is a vast amount of work underway to address thedata issues that ACT Health has been experiencing with the territory wide data Review announced by the Minister in March 2017. This is not due to conclude until early 2018. It is extremely difficult to effectively plan for the future if you do not have confidence in the data you have. And the other major activity is the completion of theUniversity of Canberra Public Hospital, the rehabilitation centre that will provide sub-acute inpatient care for older people, people who have had neurological events like strokes, and longer term mental health rehabilitation. These people will stay at the centre for their treatment and care. It will also provide a range of day programs – where consumers will attend each day but stay at home. This has to be a major focus for the Government. The opening of this centre will free up much needed clinical spaces at Canberra Hospital and Calvary that can then be used for other services.

As mentioned above, there are a number of elements that need further explanation including consideration of workforce issues and the eHealth agenda.

Workforce is a critical element of a safe and efficient health system. There are a range of initiatives that demonstrate investment in the ACT workforce, such as the University of Canberra Clinical School and the additional nursing positions. The existing ACT Workforce Plan is for 2013-2018 and there is a need to have in place strategies to address the attraction, education, recruitment and retention beyond that date, to reflect the timing of the budget initiatives. We need staff for the new services.

The eHealthy Futures that was announced in the 2010-11 budget has experienced delays. This was first announced in 2009 when the ACT Government allocated $90.2 million over four years for eHealth initiatives. It was it described as an "unprecedented level of investment" by the then Minister for Health, Katy Gallagher MLA. The intention of this commitment was to ensure our health system was better positioned to meet the needs of the ACT community at the time and into the next decade. The Budget this year says it will be complete by June 2018. There needs to be some fresh thinking on how technology can improve the quality, safety and efficiency of services .We know it is difficult but it is worth the investment to help people have better experiences and outcomes of care and improve the connection between our very fragmented health system.

A couple of highlight include:

Mobile dental clinics: The community's most vulnerable people suffer the poorest dental health. So two new mobile dental clinics should help. The larger of the two will visit schools in more disadvantaged areas. A smaller one will visit disadvantaged adults in shelters and halfway houses. Turning room and power supplies are among the challenges still to be sorted. The government will spend $2,173,000 over the next four years.

Nurse navigator positions: We are very interested in the announcement of twelve nurse navigator positions. Queensland Health introduced the role in 2015. The nurse navigator roles are clinical roles held by experienced nurses with expert clinical knowledge and in-depth understanding of the health system. Their focus is to support patients with complex health care needs to identity their needs and facilitate access to services. They support and coordinate patients across their entire journey rather than focusing on just a specific disease or condition.

HCCA has been funded in 2017-8 ($100,000) to undertake work to develop a model of patient care navigators. It will be important for us to with ACT Health in this. We are particularly interested to develop the navigator role to help educate patients about self-management of their health needs which supports people to feel empowered to make decisions on their own health care.

While the government has invested in health care services, accounting for a third of the budget, ACTCOSShas called for greater ambition to deliver on the community’s expectation for a practical plan to drive back gathering inequality. Susan Helyar said “we are disappointed that, while the Budget checks off a number of election promises, we are still not meeting the community’s expectations about action for those who face sustained long term cost of living pressures especially those who can’t find affordable and accessible housing.” Their Media Release is available online. ACTCOSS commissioned research into cost of living pressures over the past three years which revealed a persistent and widening gap between income and living costs for individuals and households living on low incomes in the ACT. 

The Budget was well received by the ACT P&C Council. Their media release is available online. The Youth Coalition welcomes elements of the budget but remains concerned that the Government does not have a plan to address education inequity and recognition of the skills, knowledge and expertise of community services in supporting students who are at risk of disengaging from school.

An update on SHOUT. Our members will be interested to learn of the ACT Government commitment to SHOUT. SHOUT supports many community groups and the government wants that to continue. The government also wants to see SHOUT with a sustainable operating model.  The government's solution is

• to await the review's findings and 

• to give $70,000 to ensure SHOUT keeps ticking over.

Pending the review's findings, SHOUT may receive recurrent funding in the 2018-19 budget. 

The Budget Papers are online:http://apps.treasury.act.gov.au/budget/budget-2017-2018/budget-papers.

The Government’s glossy overview of the health budget is available here:http://apps.treasury.act.gov.au/budget/budget-2017-2018/better-care-when-you-need-it  The Budget Papers for Heath Directorate are available herehttp://apps.treasury.act.gov.au/__data/assets/pdf_file/0007/1069369/C-Budget-Statements.pdf.

The Government is to be commended for their commitment to funding the health service to meet the needs of the community. Thirty one percent of the budget has been allocated for health services. This is $1.6 billion. The challenge for the Government is ensuring that the election commitments complement the health services planning that is currently underway within ACT Health.

We will continue to analyse the budget and share our thoughts with members via our newsletter.

Darlene Cox

Executive Director

A strong budget for healthy communities: ACT Budget 2016

Overall this is a strong health budget that continues to deliver funding to critical services for the ACT.

The commitment to enhancing services for emergency departments and trauma services is much needed. The major announcements are:
- Expanding Intensive Care ($4.6m over four years) to provide one additional bed at Canberra Hospital
- Neonatal Intensive Care ($5.3m over four years) will include two additional neonatal cots. This was always part of the plan with the new hospital bringing on line additional places as the population increased.
- Trauma Services ($5.3m over four years) expanding the major trauma service at Canberra Hospital to provide a specialised model of care.
There is money for more staff with provision made for an additional 39 staff to be hired in the next financial year at Canberra Hospital emergency department, including four new doctors and 24 nurses ($28m over four years). There is also funding for a senior emergency medicine physician at Calvary Public Hospital ($1.9m over 4 years).

Improved palliative care services ($2m over four years) providing an additional paediatric nurse. There will also be an additional palliative care specialist to provide education to treating teams across Canberra Hospital and building capability in palliative care. We are very supportive of both initiatives.

There is an allocation $6m over four years to maintain and expand drug treatment and support services in the ACT. This provides for a range of services including naloxone program, post treatment drug rehabilitation and the Alcohol Tobacco and Other Drug Association the peak body for the sector.

Stroke services at the Canberra and Calvry Public Hospital will receive $5m over four years.  This will employ an additional four specialised staff to provide more timely assessments for clot break-down treatment. This will also allow for improved availability of intra-arterial clot retrieval treatment.

There will be an expansion of outpatient services with the budget allocating $4m over four years. This will include neurology, cardiology, respiratory and sleep services.
Endoscopy services will be expanded by an additional 300 surgeries each year, with a budget cost of $1.2m over four years. This expansion is designed to reduce elective surgery waiting times.

Outreach health services for Aboriginal and Torres Strait Islander peoples will be provided with $1.2m over four years. This is to help deliver appropriate specialised care and support services through outreach services. We are very interested to hear more about this, especially given the ACT Government is in the process of finalising the ACT Aboriginal and Torres Strait Islander Health Plan 2016-2020.

Mental Health has received funding for a range of different programs and services with $43m over four years to be allocated to the staffing and operation of the soon to be open Secure Mental Health Unit. This will allow for the operation of 10 beds that is part of phase one of the Secure Mental Health Unit. There is also an allocation of $2.7m to expand the current bed numbers at the Adult Mental Health Unit from 35 to 37.

Mental health rehabilitation and follow up services will receive $2.9m to establish a Young People’s Mental Health Treatment Team for people experiencing, or at risk of developing mental health illnesses. This will allow for outreach and treatment through intervention. Any additional money for mental health services is welcome but particularly for young people as we know that this is a need.

There is a focus on funding for medical technology that is exciting. Advances in technology have made sequencing an individual’s genome a reality. Genomics is a development in health care that will likely lead to more accurate medical diagnoses and more effective and individualised treatments The Canberra Clinical Genomic Service ($7.3m over four years) will enable more personalised medicine to improve health outcomes. The other exciting aspect to genomics is the potential to reduce unnecessary and ineffective treatment, improving the experience of care of consumers, improve health outcomes and also deliver cost benefits to the health system. The Minister's media release says: "The new genomics program will build on existing research, expertise and achievements of the Centre for Personalised Immunology at the John Curtin School of Medical Research to develop genomics as part of a clinical and diagnostic service in partnership with ACT Pathology." We are pleased that the ACT Government has committed to establishing this Centre and look forward to finding out how consumers will be involved. Involving consumers in research is an important aspect of consumer and community engagement and we are interested in developing a model of participation for this Centre.

The budget includes funding for a feasibility study to assess the benefits of establishing the Australian Pancreas Centre ($200,000 for one year). There is little detail about this but we support the approach. We see that there is value in considering how ACT Health will collaborate with other bodies set up for this such as the Australian Pancreatic Genome Initiative. Pancreatic cancer is relatively uncommon representing about 2% of all new cancer diagnosis but it has high mortality and poor survival rates. It is a disease that can and does devastate families. We welcome consideration of establishing the Australian Pancreas Centre.

There is also $1.3m over four years for the introduction of deep brain stimulation services for people with Parkinson’s disease or other movement disorders. It will be for those people who derive minimal benefit from drug therapy. Deep brain stimulation is a surgical procedure and it has been used in Australia for over a decade. This procedure is offered in other capital cities so this will offer other options for ACT residents.

There are funds set aside for a range of health infrastructure which includes the construction of University Canberra Public Hospital, the much needed sub-acute rehabilitation hospital. There is $360,000 for the business development case of the new Civic Health Centre as the existing Health Centre will be relocated following the sale of 1 Moore St for the ACT Government to derive benefit from the Commonwealth Government Asset Recycling Initiative.

There is $95m for major refurbishment of existing infrastructure to ensure that these buildings meet future health needs for at least the ten years. This includes Canberra and Calvary Public Hospital and also other health facilities around the ACT, including the development of Strategic Asset Management Framework. This is imminently sensible if ageing infrastructure is to be used over the next decade. HCCA has developed a strong model for consumer participation in health infrastructure projects and while it appears that the billion dollar rebuild of the Clinical Services Building at Canberra Hospital is deferred we look forward to continued involvement to improve the existing buildings. The look and feel of health services is important, it builds our confidence in the services. We want health services we can be proud of and will serve our communities well.

The omission from our perspective is the funding for eHealth. Over the past four years there has been funding for Health-e futures, a total of $90m was allocated by the Gallagher Government to build the capability of the public health services for eHealth. There was a small amount included to advance this agenda with $250,000 allocated to determining the feasibility of migrating the Cavalry Hospital ICT infrastructure to the ACT Government network. We are hopeful that the election campaign will bring a renewed focus on eHealth as it is an important enabler of safe, high quality health care.

Darlene Cox
Executive Director

Report from a Consumer Rep - Online feedback for users, carers and providers

Below is a report by Consumer Representative Bernard Borg-Caruana on a recent session he attended on online feedback for users, carers and providers.

Online feedback for users, carers and providers

This session provided the challenges of gathering and publishing online feedback and recommended ways of increasing the potential of this avenue for users, carers and providers.

Lisa Trigg of the London School of Economics and Political Science presented on online rating and reviews for care providers.

This is in relation to the MyAgedCare website. The presentation for Aged Care  is where the Australian Government is implementing it. However in the UK it applies to all facilities and similar principles apply.

Aged Care covers:  community care, residential aged care and high care facilities.

How can you measure quality and the consumer experience?

Presentation

1. Why is it important?
2. Policy Context
3. Example
4. Challenges
5. Opportunities

Why is it Important?

Online reviews are the new word of mouth that 54% of adult consumers use before making purchases. 

• Twitter and opinions empower patients.

• We want consumer directed care and empowered consumers

• Gravity of the decision

• Difficulty of moving between providers

• Experience

You can only really assess the service once you have experienced it 

We trust providers.

UK bodies:  CMA + Care Quality Commission (CQC) +  NHS Choices all have a strong interest in this

After engaging constructively with the Competition and Markets Authority (CMA), 2 websites for finding tradespeople, Checkatrade and Trustatrader, and the care home review sites Carehome.co.uk, Care Opinion and Most Recommended Care, have all agreed to improve their practices. These improvements address concerns that were raised following a call for information by the CMA on online reviews and endorsements.

Reviews

The example is often given of Trip Advisor but some excellent lessons from Amazon (particularly regarding Fake Reviews).

Trip Advisor is usually ignored until you’re travelling somewhere where you have no experience: you have to use it.

People go out to dinner and do not review their experience but when selecting a restaurant will look at the star rating.

Some characteristics of aged care settings are “inelastic”:

1. Once you pick a facility you are unlikely to change it; even with bad experiences, a change in care, especially for dementia patients, can be detrimental but social dislocation is a factor for all residents. It is not the same as switching to a new product.

2. The gravity of the decision: How do you know that your loved one would have lived longer or had a happier life at another facility.  This is challenging in retrospect but even more challenging in Prospective decision making.

3. This is not like a diagnosis. You cannot get a second opinion. All care is individual. How can you be sure you have the right care.  

4. Cost of moving—recovering deposits

5. Choice is limited: Availability of services and proximity to the support network.

Residential Aged Care turnover is low and if there is no vacancy. It is unlikely that a consumer will check it out. Could end up with skewed reviews.

Who reviews?

Digital Inclusion reports in Australia and UK equivalent (OFCOM 2013): 

• Older people are less likely to be on the internet entering reviews. They spend less time on the internet and few push information 

• In Australia less than 10% of Indigenous Aboriginal's have IT access outside cities.

Wisdom of crowds – Surowiecki, 2004

Motivations: Some are altruistic and want to help others make better decisions but others think they can help the providers improve service

How do you know you’re getting a trusted reviewer? Some sites publish a number of reviews performed by a reviewer --- may not be useful in aged care as turnover is low.

Fake reviews— are big business – Amazon is suing publishers and providers of fake reviews.

Fake reviews by providers are a big issue and difficult to manage.

Positive reviews of their business and negative reviews for competitors—See Amazon’s experience

One review in the UK described a facility as excellent; 4 reviews over 3 years said 2 average and 2 terrible; NHS assessment, many areas were average and many below par and is always bordering on being closed down.

Accountability

Laws --- ACCC in Australia – false and misleading claims--  

You can also be held responsible for posts or public comments made by others on your social media pages which are false or likely to mislead or deceive consumers.

Businesses using social media channels like Facebook, Twitter and YouTube have a responsibility to ensure content on their pages is accurate, irrespective of who put it there.

Monitor your social media pages 

Barriers

Access to technology

Sufficient knowledge – technical knowledge to assess all aspects of the facility

Some large organisations may get good average reviews but may have a terrible eg chemotherapy unit ie not all services are the same.

Sometimes the people in the home are not in a position to advise you if they are getting the right care eg dementia patients.

Fear of reprisal and retribution – if you see bruising on your parent in a home ---

For effective review system:  the Government MUST look at defamation laws.

What consumers want:

1. Peer discussion; to meet privately with 1-2 people who had experience with a facility.

2. Stories override rating systems. If someone tells you a story, it often trumps the raw statistics and will sway you.

3. Accountability and reliable reviews

4. Reviews are not a substitute for an effective complaints system and need to be kept separate.

5. Advice to consumers:    Never rely on one source.

Difference in UK

Rating is linked to Pricing:  ie if you have 4+ star rating you can charge above $230 but if you have 3 stars you can charge a max of $230,  etc…

References

Digital Inclusion reports in Australia 

UK equivalent (OFCOM 2013: 

Wisdom of crowds – Surowiecki, 2004

Motivation of Reviewers – Sundaram et al 1998

Ubel 2001

Recognition of Reviewers

CMA report 2016 (Competition and Marketing Authority )

https://www.gov.uk/government/news/online-review-sites-commit-to-improve-practices

https://www.gov.uk/government/speeches/alex-chisholm-on-the-role-of-consumer-enforcers-in-a-changing-environment

By Bernard Borg-Caruana

Wifi at Canberra Hospital

Update from ACT Heatlh:

ACT Health is continuing the implementation of a wireless (Wi-Fi) internet facility for our healthcare consumers and their visitors. This will allow people to use their own Wi-Fi enabled devices to browse the internet and keep up to date with their e-mails.

Currently, free Wi-Fi is available within Paediatrics, Ward 12B (Rehabilitation), Oncology, Central Outpatients, Emergency Department and Renal Services. These areas were selected to participate in a trial of public internet access, which commenced in mid-2013.

Over the next month, public internet access will be implemented at community health centres in Belconnen, Gungahlin and Tuggeranong; and within additional areas of the Canberra Hospital, including: Buildings 1, 3, 7, 8, 11 and 12. In addition, discussions will be undertaken with business areas located in Buildings 2, 10, 19 and 25 to identify suitable areas for the location of public Wi-Fi hotspots.

The public internet facility builds on the existing wireless network (TUTD), which enables staff to access the ACT Health network using ACT Government laptops and authorised iPads/iPhones which have been secured using the Mobile Iron mobile device management app. Also available on the Canberra Hospital Campus is the ANU wireless network, which provides access for ANU students and staff.

Public internet access is filtered for appropriateness, and access is capped to avoid excessive cost to Government. Service levels are designed primarily for browsing the internet and accessing e-mails.

Consumers need to opt in to ehealth records

Adam Cresswell wrote a piece in last week’s Weekend Australian highlighting concerns raised by doctors and consumer groups about likely low take-up rates for the electronic health records and calling for basic changes to keep the scheme on track.  The article focuses on comments from CHF in its submission to the Senate inquiry on the legislation to the program, in which it argues in favour of an opt-out, rather than an opt-in system. 

HCCA also presented a submission to this inquiry, strongly supporting the opt-in model.  This view is based on discussion of consumer members of the ACT ehealth Consumer Reference Group.

In an ideal world, opt-out has many strong arguments in its favour.  However, the reality of getting the PCEHR successfully implemented requires giving up some health data principles.  The introduction of the PCEHR represents a major shift in public perception and if the system to realise its potential, both health care providers and health care consumers need to be supportive and to be supported.  We are not there yet!

If everyone has a PCEHR, but few access it, what use is that?  Let those that know about it and want it be the trail seekers.  We have to start slowly otherwise it will fail.

There is also an issue around the incentives that are required to entice practitioners to become nominated providers in the system.  There is considerable discussion around the need for the Government to provide payment.  Why should the medical profession take on more tasks without being paid?  No amount of saying in the long run it will be beneficial to clinicians and their patients will bring about the change needed.  The demand for the time of our clinicians is strong and in some areas we do not have enough clinician to meet the needs of our communities. Some feel strongly that to expect them to add to their workload is a big ask and would mean other 'services' can't be provided.  A mechanism to engage clinicians to become nominated providers and to upload documents to the PCEHR has to be agreed soon so that consumers are not disadvantaged.

HCCA understands why the Government has adopted an “opt in” policy for consumer participation in the system and continues to support it, although we remain concerned that allowing clinicians to withhold records from the system may disadvantage consumers who choose to opt in and that some form of mechanism to limit this possibility needs to be incorporated in the EHR implementation. This, we believe, will enable it to better cater to consumer needs.

Darlene Cox

Executive Director