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Australian health system restructuring – what problem is being solved?

Australian health system restructuring – what problem is being solved? Background: In recent years, Australian state and territory governments have reviewed and restructured the health systems they lead and regulate. This paper examines the outcomes of the most recent official published reviews of systems and structures; identifies the common themes; and addresses two questions: what problems are being addressed? And how would we know if the changes were successful? Results: In all the broad, systemic reviews, the main health system problems identified were money, hospital utilisation and a weak primary health care system. The solutions are various, but there is a common trend towards centralisation of governance, often at state health authority level, and stronger accountability measures. Other common themes are hospital substitution (services to avoid the need for admission); calls for cooperation across the Commonwealth:state divide, or for its abolition; and the expected range of current efficiency and effectiveness measures (eg amalgamate pathology and support services) and ideas in good currency (eg call centres). The top- down nature of the public review process is noted, along with the political nature of the immediate catalysts for calling on a review. Conclusion: The long-standing tension between the pull to centralisation of authority and the need for innovation in care models is heightened by recent changes, which may be counterproductive in an era dominated by the burden of chronic disease. I argue that the current reforms will not succeed in achieving the stated goals unless they make a difference for people with chronic illness. And if this is correct, the most useful focus for evaluation of the success of the reforms may be their impact on the system's ability to develop and deliver better models of care for this growing group of patients. This paper examines the outcomes of the most recent offi- Background In recent years, there has been a rolling (and sometimes cial published reviews of systems and structures; identifies repetitive) tide of structural change in the way state and the common themes; and addresses two questions: what territory governments organise to lead and/or provide problems are being addressed? And how would we know health care within their jurisdictions, with every state and if the changes were successful? territory of Australia involved at least once in the last 10 years. Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 Table 1: Review Dateline Year States Year States 2004 WA, NSW, Tasmania (hospitals only) 2000 Victoria 2003 NSW, Victoria#, SA, NT 1996 Tasmania, Qland, ACT 2002 ACT, 1995 Victoria, SA 2001 WA Notes: #No major structural changes recommended – focus on governance This analysis focuses on those reviews which are 'systemic' different process than the others undergoing structural in the sense that they examine broadly the structure and change, with a brief booklet announcing and explaining performance of a state/territory health system, and/or the decision [1], rather than extended public review proc- address governance of the system. The NSW restructure esses with opportunities for community and health serv- has been included, although it differs from the others in ice provider input. the absence of an independent review process and in the related lack of detailed documentation of the rationale for The trend: centralisation of governance change. In what has emerged as a strong centralising tendency, 6 of 8 jurisdictions have centralised governance authority Review of reviews for public sector health care agencies at the level of the The most recent wave of systemic reviews in the Australian state or territory health authority. Victoria and South Aus- public health system saw New South Wales [1], South tralia are mixed, with regionalised or 'networked' struc- Australia [2], the Northern Territory [3], Western Australia tures predominating in the capital city; and several [4] and the Australian Capital Territory [5] go in for different approaches to both regional and institutional restructuring. Victoria reviewed metropolitan health sys- governance elsewhere. As Somgen points out, Victoria and tem governance [6], but pulled back from major structural South Australia were the states most strongly influenced change, having had a round of it in 2000 [7]. by the 1990's trend to privatisation, outsourcing and out- put-based funding [12], with less focus on structures and NSW has relinquished its status as an island of relative sta- central planning. bility, which had been maintained since 1986 in spite of several reviews, penultimately by IPART [8]. In the after- Table 2 summarises the current arrangements by state, in math of a scandal at MacArthur Health Service [9], the order of population size, with the population shown in Minister announced the abolition of all Area Health Serv- brackets in the left-hand column (M = million). ice boards, and is restructuring the health services into 8 'super-regions' with CEO's who report directly to the head The recent NSW decision means that there is now a strong of the Department [1]. Clinicians and the community will predominance of governance at state health authority be represented on advisory structures, and a new agency level, with two-thirds of the Australian population living will take over support functions. in areas served by centralised health services. Queensland stays with central control (virtually no boards The second notable trend is the virtual end of 'atomised' of governance to dilute the Department's authority) while structures – stand-alone, single-service agencies (ie, hospi- Tasmania is reviewing hospital services only [10], having tals, community health, or mental health services) in the restructured in 1991 (from 'atomised' to regionalised) public sector. There are of course exceptions (women's and 1997 (from regionalised to centralised) [11]. and children's hospitals may be the last ones standing in a few years), and the picture is different for non-govern- ment organisations (like district nursing) which are less Results The pattern of systemic reviews over the last 10 years is amenable to restructuring. summarised in Table 1. One notable trend is that the deci- sion to review is often no longer presented publicly as a Common Themes matter solely for the health minister. The premier or a The most recent reviews in WA and SA are characterised by financial/regulatory arm of government (mostly in con- claims to radical change, based on both financial and cert with the health minister) commissioned the most health goals: recent reviews in Western Australia, South Australia, and the Northern Territory. The NSW restructure arises from a Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 Table 2: Governance of public health care agencies in Australian states/territories State Current Status Recent changes NSW 6.64M Centralising by 1 January 2005; regionalised since Moving from 17 Area Health Services with separate 1986. governance authority to 8 Area Health Services within Departmental governance. Victoria 4.87M Rurals partly regionalised for many years; Melbourne Melbourne networks restructured from 7 to 12 and names 'networked' since 1995. changed in 2000. Rural structures mix of regionalised and atomised. Q'land 3.71M Centralised at state level since 1996 after 5 years of Long history of centralisation with advisory hospital regionalisation. boards; Regional Health Authorities 1991–1996. WA 1.93M Centralised at state level in 2001/02. Moved from 'atomised' in Perth to one board in 1997, governance centralised in 2001; state now centralised. SA 1.52M Regionalised in rural areas since 1995; Adelaide partly Moved from atomised to regionalised, with 2 regional and 1 regionalising. specialised health services in the capital as of July 2004. Tasmania 0.47M Centralised at state level Moved from atomised to regionalised in 1991; centralised at state level in 1997. ACT 0.32M Centralised (single city system) Single board for Canberra established in 1996; abolished in 2002. NT 0.2M Centralised at territory Level Never devolved. Some autonomous Aboriginal Health Services. '...incremental reform is no longer the pathway to a financially tell a familiar story of the need to bring increases in state sustainable vision for WA. A fundamental re-prioritisation of health spending to sustainable levels, set against the trend the public health system is needed, and should be carried out of increasing costs due to increasing incidence of chronic over the next decade in a systematic and integrated way' [4], p disease, and more technologies for intervention, in an v). ageing population. They all focus on the need to improve quality and safety for patients. 'The people of South Australia have a decision to make on what type of health system they need now and for the future genera- The reviews also find that the health system is too frag- tion...there needs to be a significant shift from a system focused mented to meet the needs of patients with long-term com- on illness to a health system reoriented towards health promo- plex conditions well. This is seen to be partly because the tion, illness prevention and early intervention' [2]p xiii. system was designed for acute illness, with the current funding mechanisms also designed primarily on the pat- Western Australia is taking on the tertiary hospitals, and tern of acute interventions. The reviews call for better inte- reducing the number of tertiary sites from 5 to 2 (with the gration of services, so that navigating the system is easier women's and children's hospital group to be collocated for patients, their carers and care providers. but organisationally separate). All state-run health serv- ices are to report through three metropolitan regions The reviews consistently argue that in order to achieve (north, south and Women's and Children's) and one rural this, the primary care system needs to be more effective in region, with the CEO's reporting directly to the Depart- managing or coordinating patients' needs for several dif- ment – there are to be no boards of governance. South ferent kinds of services when and where they are needed. Australia has succeeded in amalgamating most of The inevitable corollary is that inpatient care and hospi- Adelaide's hospital and community health boards to form tals have to become less central in the organisation and 2 regional health services and 1 child, youth and women's funding of the system. What can be done elsewhere health service (incorporating the women's and children's should be; and the primary care level must have more of hospital). This is a notable achievement for a minority the action and more of the pulling power. government, after at least five separate attempts in the last 20 years to rebalance power and responsibility had largely In turn, this will require different facilities for different failed [13-17]. modes of service delivery; different funding allocations and methods of allocation; and a solution to the atomisa- Not all of the systemic reviews claim to set a bold new tion of primary care caused by the Commonwealth/state vision, but there are strong common themes. The reports split and the current model of fee-for-service medicine. Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 The need for changes in the private sector is noted in the only one. I refer not so much to important policy settings reviews, but proposals are not developed, because the (like funding allocation models and public health priori- states have such a limited role here. ties) which are studied and articulated in publicly-availa- ble documents, but rather to the influence of Much is also made of the need for providers to be more administrative decisions (like who gets special grants and accountable to government and the community, and/or who doesn't) and the effectiveness of relationships with better governed and managed. While the reports mostly health care provider organisations (as judged from the call for less micro-managing from the head offices of bottom up as well as the top down). The administrative health authorities, and a better separation between the actions of health authorities seem to go largely roles of central policy-makers and peripheral service pro- unexamined. viders (or regional CEO's), there is also a countervailing tendency to recommend tighter engagement and control. Secondly, while the underlying problems the reviews set For example, the Kibble review of governance in Victoria out to address are all about money, hospital utilisation (2003) notes confusion about relative roles and responsi- and a weak primary health care system, the immediate bilities and calls for the Department of Human Services to context is often the election of a new government (Victo- reduce 'attention to the day-to-day operations of Health ria, SA, NT), the appointment of a new minister or health Services and monitoring of detailed activities' (p 27) but authority CEO (WA), media unrest about health in a state later recommends 'a standardised reporting template' for with a looming election (ACT) or scandal (NSW). This internal reports to boards across the system (p 35), along observation may simply be another way of saying that the with stronger accountability for the CEOs to the Secretary health portfolio is highly politically sensitive as well as of the Department. More public reporting of service out- complex, and so risky that reference to independent comes and activity levels is a related common theme, expertise is seen as essential. intended to inform the public and to underpin attention to safety and quality. Discussion The main line of logic running through the recent reviews The final major common theme in the reviews is the seems sound. The primary care system needs strengthen- inclusion of an opportunistic range of technical efficiency ing; what can be done outside hospitals should be; and a and effectiveness measures, picking up ideas in good cur- continuing focus on safety, performance and accountabil- rency or known productivity opportunities. For example, ity is necessary. almost everyone recommends a call centre; a web-based method of sharing innovations; amalgamation of support The reports also make it clear that this is all about services where relevant; and improvements in the effec- responding to the major challenge for the system: to tiveness of information systems and the use of improve its capacity to prevent, intervene early in, and information. manage chronic disease, the main driver of increased demand. Such a focus is clearly justified. Chronic disease There are two other commonalities worth noting. Firstly, is responsible for approximately 80% of the total burden it is a fact of organisational and political life that official of disease, with an estimated three million Australians reviews are a top-down affair, commissioned by one level suffering from one or more chronic illnesses [18]. About of the system to examine a lower level. Thus it is not sur- 40% of total health expenditure, or $12.6 billion, was prising that there are no published official reviews of the spent on chronic illness in 1993/94, just less than half of roles and responsibilities of the Commonwealth health it in hospitals [19]. The system must be able to deliver the authority in the last twenty years. When the published kind of care needed by people with (or at risk of) chronic reviews do address the roles and responsibilities of state disease, including older people and Indigenous people, health authorities, it is either because they are the provid- and thereby enhance the system's effectiveness and per- ers (NT, WA, ACT) or because intended changes to the haps even reduce the slope of the increasing cost curve. service provider level of the system require changes to the roles of central health authorities. If this is the imperative, the trend away from atomised governance structures, and towards bringing multiple This is an important limitation in the current environ- agencies which serve (at least some) common patients ment, when some of the key barriers to improving the together, seems like the right direction. But there is effectiveness of health care delivery lie in the system's sel- another important requirement which may not be served dom seen upper reaches. As the reviews note, the way that by these moves – that is, a stronger focus on innovation in the Commonwealth/state split of responsibility for health care models. While recommendations abound, we don't is enacted and managed is probably the single most signif- yet really know what will work best for the new pattern of icant problem in health system design. But it is not the Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 illness – how do you best coordinate care around the public hospitals and health services is less likely to be needs of the chronicly ill? driven by clinicians who are more tightly controlled, staff who have learnt to be risk-averse, or managers who are Uncertainty about care models, and the institutional and increasingly frightened of tomorrow's headlines, and policy arrangements needed to support them, can only be whose planning horizon extends to next month's finan- resolved through the continued development and testing cial and activity data. This problem is only compounded of innovative approaches, on the ground in health care while hospitals and community health services on the one delivery, as happened most notably with the Coordinated hand, and GPs on the other, continue to work with so lit- Care Trials [20]. As many of the reviews argue, the engage- tle in the way of common incentives. ment of clinicians is critical to this endeavour. Conclusion This reality implies that there is a secondary criterion by The recent reviews were established largely to address which the effectiveness of health system structural financial imperatives in an environment of upward pres- changes might be judged: do the changes enhance or sure on demand for services, and accountability concerns inhibit the system's ability to innovate? The requirement (in relation to quality and safety, and general good gov- for innovation and experimentation may not sit comfort- ernance), mostly in a highly political context. The review- ably with government requirements for standardisation of ers rightly sought to take a longer-term strategic known good practice. However in an area where best prac- perspective. They attempted (with varying degrees of suc- tice is not known, innovation is critical, and must be cess) to focus on good system design and capacity to meet supported. the broad and complex purposes of public health systems, recognizing the growing challenges the systems face. Unfortunately, the Commonwealth:state responsibility split, the one structural barrier most central to the sys- Structural reform is hardly ever evaluated, other than temic weakness of Australian primary care (and therefore when its weaknesses are articulated by those proposing most important for the capacity to develop and support the next round of changes, as part of the rationale for their new models of care for chronic diseases), is one that a efforts. There are many reasons for this failure, some of state can't address, at least not alone. The Productivity them political. One pertinent reason is that outcomes like Commission's recent call for an independent public containing the pressure of future growth in demand, or review of the whole health system [21], focused on over- improving health outcomes for the population, cannot be lapping roles and responsibilities for funding, offers judged within a realistic time frame. grounds to hope for movement in this otherwise intracta- ble problem. However, in the current environment, with strong conver- gence in the themes addressed by a fairly comprehensive The other pessimistic sign is the trend to more direct con- round of reviews of Australian health systems, an argu- trol of health care provision by state governments, related ment can be made for evaluation 'at the pointy end' of the no doubt to the twin problems of increasing demand (and changes. Given the challenges the reviews were intended therefore cost) and increasing disclosure of safety and to address, there are grounds to suggest that the current quality problems, both of which can only politicise the reforms will not succeed in achieving the stated (shorter- system more. Research on innovation, in relation to qual- and longer-term) goals unless they make a difference for ity and safety as well as other performance measures, indi- people with chronic illness. And if this is correct, the most cates that micro-management from above is not helpful useful immediate focus for evaluation of the success of the [22,23]. reforms may be their impact on the system's ability to develop and deliver better models of care for this growing Local evidence to support this view is scant. While the group of patients. effectiveness of the new arrangements during Queens- land's brief period of devolved governance was judged Methods harshly when it came time to re-centralise, some com- The 'data' for this project were the published reports of mentators suggest that this period also allowed Queens- systemic reviews of the health systems, and related land to catch up to other states in areas like accreditation, material published on departmental websites and in the casemix, IT and 'attention to performance management professional and academic literature. and outcomes' [24]. These sources were analysed to generate an understanding This may be a critical problem. While recognising that per- of the recommended governance authority structures; and spectives on this question are highly related to one's place the common themes emerging from the reasoning on in the structure, I would suggest that real innovation in which the recommendations were based. The themes Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 23. National Institute of Clinical Studies: Factors supporting high per- underpinning the recommendations were then assessed formance in health care organisations. Melbourne; 2003. in the light of the overarching goals of reform. 24. Surrao S, Taylor G, Turner A, Donald K: Hospital funding and services in Queensland. Aust Health Rev 2002, 25:99-120. Competing Interests I was a member of the South Australian 'Generational Health Review' Steering Committee, chaired its Govern- ance and Funding Task Force and continue to consult to the SA Department of Human Services. I worked for twenty years in health care agencies, and only one in a central health authority. References 1. NSW Department of Health: Planning Better Health: Back- ground Information July 2004. Sydney; 2004. 2. Generational Health Review: Better Choices Better Health: Final Report of the South Australian Generational Health Review. Adelaide: Government of South Australias; 2003. 3. Banscott Health Consulting: Report of the Review of the North- ern Territory Department of Health and Community Services. Darwin: Department of Health and Community Services; 4. Reid M, Daube M, Langonlant J, Saffioti R, Cloughan D: A healthy future for Western Australians: Report of the Health Reform Committee. Perth, W A Department of Health; 2004. 5. Reid M, and associates: ACT Health Review. Canberra: ACT Health Department; 2002. 6. Kibble and Associates: Victorian Public Hospital Governance Reform Panel Report. Melbourne, Victorian Department of Human Services; 2003. 7. Duckett SJ, Capp S, Carter M, Lowe E, Zimet A: Ministerial Review of Health Care Networks: Final Report. Melbourne: Victorian Department of Human Services; 2000. 8. Independent Pricing and Regulatory Tribunal of New South Wales: NSW Health: Focusing on patient care. Sydney; 2003. 9. Walker BW: Final Report of the Special Commission into Events at Campbelltown and Camden Hospitals. Sydney, NSW Department of Health; 2004. 10. Shannon E: Expert Advisory Group examine key issues for Tasmanian public and private hospital systems. Links Quarterly 2003:p.8. 11. Duckett S, Greeves P, Kinne L, Ratcliffe K: Hospital services in Tasmania. Aust Health Rev 2002, 26:141-155. 12. Somjen A: Distinguishing Features of Reform in Australia and New Zealand. In Health Reform in Australia and New Zealand Edited by: Bloom A. Melbourne: Oxford University Press; 2000:55-68. 13. Uhrig JA: Report of the Review of Metropolitan Hospital Administrative Arrangements and Responsibilities. Adelaide: Government of South Australia; 1986. 14. Taeuber K: Review of the Commission's Central Office. Adelaide: S A Health Commission; 1986. 15. South Australian Health Commission: Green Paper: Area Health Service Administration in South Australia. Adelaide, SA Health Commission; 1991. 16. South Australian Health Commission: The organisation of health services in South Australia: a response to the Discussion Paper (Green Paper) on Area Health Service Administra- Publish with Bio Med Central and every tion in South Australia. Adelaide; 1992. 17. South Australian Commission of Audit: Report of the S A Com- scientist can read your work free of charge mission of Audit. Adelaide, Government of South Australia; 1994. "BioMed Central will be the most significant development for 18. Australian Institute of Health and Welfare: Chronic diseases and disseminating the results of biomedical researc h in our lifetime." associated risk factors in Australia 2001. Canberra; 2002. 19. Australian Institute of Health and Welfare: Australia's Health Sir Paul Nurse, Cancer Research UK 2002. Canberra; 2002. Your research papers will be: 20. Department of Health and Aged Care: The Australian Coordi- nated Care Trials: Interim Technical National Evaluation available free of charge to the entire biomedical community Report. Canberra: Commonwealth of Australia; 2000. peer reviewed and published immediately upon acceptance 21. Productivity Commission: Review of National Competition Pol- icy Reforms: Draft Report. Canberra; 2004. cited in PubMed and archived on PubMed Central 22. Ferlie E B and Shortell SM: Improving the Quality of Health Care yours — you keep the copyright in the United Kingdon and the United States: A Framework for Change. The Milbank Quarterly 2001, 79:281 -315. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Australian health system restructuring – what problem is being solved?

Dwyer, Judith
Australia and New Zealand Health Policy , Volume 1 (1) – Nov 19, 2004
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Springer Journals
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Copyright © 2004 by Dwyer; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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10.1186/1743-8462-1-6
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Abstract

Background: In recent years, Australian state and territory governments have reviewed and restructured the health systems they lead and regulate. This paper examines the outcomes of the most recent official published reviews of systems and structures; identifies the common themes; and addresses two questions: what problems are being addressed? And how would we know if the changes were successful? Results: In all the broad, systemic reviews, the main health system problems identified were money, hospital utilisation and a weak primary health care system. The solutions are various, but there is a common trend towards centralisation of governance, often at state health authority level, and stronger accountability measures. Other common themes are hospital substitution (services to avoid the need for admission); calls for cooperation across the Commonwealth:state divide, or for its abolition; and the expected range of current efficiency and effectiveness measures (eg amalgamate pathology and support services) and ideas in good currency (eg call centres). The top- down nature of the public review process is noted, along with the political nature of the immediate catalysts for calling on a review. Conclusion: The long-standing tension between the pull to centralisation of authority and the need for innovation in care models is heightened by recent changes, which may be counterproductive in an era dominated by the burden of chronic disease. I argue that the current reforms will not succeed in achieving the stated goals unless they make a difference for people with chronic illness. And if this is correct, the most useful focus for evaluation of the success of the reforms may be their impact on the system's ability to develop and deliver better models of care for this growing group of patients. This paper examines the outcomes of the most recent offi- Background In recent years, there has been a rolling (and sometimes cial published reviews of systems and structures; identifies repetitive) tide of structural change in the way state and the common themes; and addresses two questions: what territory governments organise to lead and/or provide problems are being addressed? And how would we know health care within their jurisdictions, with every state and if the changes were successful? territory of Australia involved at least once in the last 10 years. Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 Table 1: Review Dateline Year States Year States 2004 WA, NSW, Tasmania (hospitals only) 2000 Victoria 2003 NSW, Victoria#, SA, NT 1996 Tasmania, Qland, ACT 2002 ACT, 1995 Victoria, SA 2001 WA Notes: #No major structural changes recommended – focus on governance This analysis focuses on those reviews which are 'systemic' different process than the others undergoing structural in the sense that they examine broadly the structure and change, with a brief booklet announcing and explaining performance of a state/territory health system, and/or the decision [1], rather than extended public review proc- address governance of the system. The NSW restructure esses with opportunities for community and health serv- has been included, although it differs from the others in ice provider input. the absence of an independent review process and in the related lack of detailed documentation of the rationale for The trend: centralisation of governance change. In what has emerged as a strong centralising tendency, 6 of 8 jurisdictions have centralised governance authority Review of reviews for public sector health care agencies at the level of the The most recent wave of systemic reviews in the Australian state or territory health authority. Victoria and South Aus- public health system saw New South Wales [1], South tralia are mixed, with regionalised or 'networked' struc- Australia [2], the Northern Territory [3], Western Australia tures predominating in the capital city; and several [4] and the Australian Capital Territory [5] go in for different approaches to both regional and institutional restructuring. Victoria reviewed metropolitan health sys- governance elsewhere. As Somgen points out, Victoria and tem governance [6], but pulled back from major structural South Australia were the states most strongly influenced change, having had a round of it in 2000 [7]. by the 1990's trend to privatisation, outsourcing and out- put-based funding [12], with less focus on structures and NSW has relinquished its status as an island of relative sta- central planning. bility, which had been maintained since 1986 in spite of several reviews, penultimately by IPART [8]. In the after- Table 2 summarises the current arrangements by state, in math of a scandal at MacArthur Health Service [9], the order of population size, with the population shown in Minister announced the abolition of all Area Health Serv- brackets in the left-hand column (M = million). ice boards, and is restructuring the health services into 8 'super-regions' with CEO's who report directly to the head The recent NSW decision means that there is now a strong of the Department [1]. Clinicians and the community will predominance of governance at state health authority be represented on advisory structures, and a new agency level, with two-thirds of the Australian population living will take over support functions. in areas served by centralised health services. Queensland stays with central control (virtually no boards The second notable trend is the virtual end of 'atomised' of governance to dilute the Department's authority) while structures – stand-alone, single-service agencies (ie, hospi- Tasmania is reviewing hospital services only [10], having tals, community health, or mental health services) in the restructured in 1991 (from 'atomised' to regionalised) public sector. There are of course exceptions (women's and 1997 (from regionalised to centralised) [11]. and children's hospitals may be the last ones standing in a few years), and the picture is different for non-govern- ment organisations (like district nursing) which are less Results The pattern of systemic reviews over the last 10 years is amenable to restructuring. summarised in Table 1. One notable trend is that the deci- sion to review is often no longer presented publicly as a Common Themes matter solely for the health minister. The premier or a The most recent reviews in WA and SA are characterised by financial/regulatory arm of government (mostly in con- claims to radical change, based on both financial and cert with the health minister) commissioned the most health goals: recent reviews in Western Australia, South Australia, and the Northern Territory. The NSW restructure arises from a Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 Table 2: Governance of public health care agencies in Australian states/territories State Current Status Recent changes NSW 6.64M Centralising by 1 January 2005; regionalised since Moving from 17 Area Health Services with separate 1986. governance authority to 8 Area Health Services within Departmental governance. Victoria 4.87M Rurals partly regionalised for many years; Melbourne Melbourne networks restructured from 7 to 12 and names 'networked' since 1995. changed in 2000. Rural structures mix of regionalised and atomised. Q'land 3.71M Centralised at state level since 1996 after 5 years of Long history of centralisation with advisory hospital regionalisation. boards; Regional Health Authorities 1991–1996. WA 1.93M Centralised at state level in 2001/02. Moved from 'atomised' in Perth to one board in 1997, governance centralised in 2001; state now centralised. SA 1.52M Regionalised in rural areas since 1995; Adelaide partly Moved from atomised to regionalised, with 2 regional and 1 regionalising. specialised health services in the capital as of July 2004. Tasmania 0.47M Centralised at state level Moved from atomised to regionalised in 1991; centralised at state level in 1997. ACT 0.32M Centralised (single city system) Single board for Canberra established in 1996; abolished in 2002. NT 0.2M Centralised at territory Level Never devolved. Some autonomous Aboriginal Health Services. '...incremental reform is no longer the pathway to a financially tell a familiar story of the need to bring increases in state sustainable vision for WA. A fundamental re-prioritisation of health spending to sustainable levels, set against the trend the public health system is needed, and should be carried out of increasing costs due to increasing incidence of chronic over the next decade in a systematic and integrated way' [4], p disease, and more technologies for intervention, in an v). ageing population. They all focus on the need to improve quality and safety for patients. 'The people of South Australia have a decision to make on what type of health system they need now and for the future genera- The reviews also find that the health system is too frag- tion...there needs to be a significant shift from a system focused mented to meet the needs of patients with long-term com- on illness to a health system reoriented towards health promo- plex conditions well. This is seen to be partly because the tion, illness prevention and early intervention' [2]p xiii. system was designed for acute illness, with the current funding mechanisms also designed primarily on the pat- Western Australia is taking on the tertiary hospitals, and tern of acute interventions. The reviews call for better inte- reducing the number of tertiary sites from 5 to 2 (with the gration of services, so that navigating the system is easier women's and children's hospital group to be collocated for patients, their carers and care providers. but organisationally separate). All state-run health serv- ices are to report through three metropolitan regions The reviews consistently argue that in order to achieve (north, south and Women's and Children's) and one rural this, the primary care system needs to be more effective in region, with the CEO's reporting directly to the Depart- managing or coordinating patients' needs for several dif- ment – there are to be no boards of governance. South ferent kinds of services when and where they are needed. Australia has succeeded in amalgamating most of The inevitable corollary is that inpatient care and hospi- Adelaide's hospital and community health boards to form tals have to become less central in the organisation and 2 regional health services and 1 child, youth and women's funding of the system. What can be done elsewhere health service (incorporating the women's and children's should be; and the primary care level must have more of hospital). This is a notable achievement for a minority the action and more of the pulling power. government, after at least five separate attempts in the last 20 years to rebalance power and responsibility had largely In turn, this will require different facilities for different failed [13-17]. modes of service delivery; different funding allocations and methods of allocation; and a solution to the atomisa- Not all of the systemic reviews claim to set a bold new tion of primary care caused by the Commonwealth/state vision, but there are strong common themes. The reports split and the current model of fee-for-service medicine. Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 The need for changes in the private sector is noted in the only one. I refer not so much to important policy settings reviews, but proposals are not developed, because the (like funding allocation models and public health priori- states have such a limited role here. ties) which are studied and articulated in publicly-availa- ble documents, but rather to the influence of Much is also made of the need for providers to be more administrative decisions (like who gets special grants and accountable to government and the community, and/or who doesn't) and the effectiveness of relationships with better governed and managed. While the reports mostly health care provider organisations (as judged from the call for less micro-managing from the head offices of bottom up as well as the top down). The administrative health authorities, and a better separation between the actions of health authorities seem to go largely roles of central policy-makers and peripheral service pro- unexamined. viders (or regional CEO's), there is also a countervailing tendency to recommend tighter engagement and control. Secondly, while the underlying problems the reviews set For example, the Kibble review of governance in Victoria out to address are all about money, hospital utilisation (2003) notes confusion about relative roles and responsi- and a weak primary health care system, the immediate bilities and calls for the Department of Human Services to context is often the election of a new government (Victo- reduce 'attention to the day-to-day operations of Health ria, SA, NT), the appointment of a new minister or health Services and monitoring of detailed activities' (p 27) but authority CEO (WA), media unrest about health in a state later recommends 'a standardised reporting template' for with a looming election (ACT) or scandal (NSW). This internal reports to boards across the system (p 35), along observation may simply be another way of saying that the with stronger accountability for the CEOs to the Secretary health portfolio is highly politically sensitive as well as of the Department. More public reporting of service out- complex, and so risky that reference to independent comes and activity levels is a related common theme, expertise is seen as essential. intended to inform the public and to underpin attention to safety and quality. Discussion The main line of logic running through the recent reviews The final major common theme in the reviews is the seems sound. The primary care system needs strengthen- inclusion of an opportunistic range of technical efficiency ing; what can be done outside hospitals should be; and a and effectiveness measures, picking up ideas in good cur- continuing focus on safety, performance and accountabil- rency or known productivity opportunities. For example, ity is necessary. almost everyone recommends a call centre; a web-based method of sharing innovations; amalgamation of support The reports also make it clear that this is all about services where relevant; and improvements in the effec- responding to the major challenge for the system: to tiveness of information systems and the use of improve its capacity to prevent, intervene early in, and information. manage chronic disease, the main driver of increased demand. Such a focus is clearly justified. Chronic disease There are two other commonalities worth noting. Firstly, is responsible for approximately 80% of the total burden it is a fact of organisational and political life that official of disease, with an estimated three million Australians reviews are a top-down affair, commissioned by one level suffering from one or more chronic illnesses [18]. About of the system to examine a lower level. Thus it is not sur- 40% of total health expenditure, or $12.6 billion, was prising that there are no published official reviews of the spent on chronic illness in 1993/94, just less than half of roles and responsibilities of the Commonwealth health it in hospitals [19]. The system must be able to deliver the authority in the last twenty years. When the published kind of care needed by people with (or at risk of) chronic reviews do address the roles and responsibilities of state disease, including older people and Indigenous people, health authorities, it is either because they are the provid- and thereby enhance the system's effectiveness and per- ers (NT, WA, ACT) or because intended changes to the haps even reduce the slope of the increasing cost curve. service provider level of the system require changes to the roles of central health authorities. If this is the imperative, the trend away from atomised governance structures, and towards bringing multiple This is an important limitation in the current environ- agencies which serve (at least some) common patients ment, when some of the key barriers to improving the together, seems like the right direction. But there is effectiveness of health care delivery lie in the system's sel- another important requirement which may not be served dom seen upper reaches. As the reviews note, the way that by these moves – that is, a stronger focus on innovation in the Commonwealth/state split of responsibility for health care models. While recommendations abound, we don't is enacted and managed is probably the single most signif- yet really know what will work best for the new pattern of icant problem in health system design. But it is not the Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 illness – how do you best coordinate care around the public hospitals and health services is less likely to be needs of the chronicly ill? driven by clinicians who are more tightly controlled, staff who have learnt to be risk-averse, or managers who are Uncertainty about care models, and the institutional and increasingly frightened of tomorrow's headlines, and policy arrangements needed to support them, can only be whose planning horizon extends to next month's finan- resolved through the continued development and testing cial and activity data. This problem is only compounded of innovative approaches, on the ground in health care while hospitals and community health services on the one delivery, as happened most notably with the Coordinated hand, and GPs on the other, continue to work with so lit- Care Trials [20]. As many of the reviews argue, the engage- tle in the way of common incentives. ment of clinicians is critical to this endeavour. Conclusion This reality implies that there is a secondary criterion by The recent reviews were established largely to address which the effectiveness of health system structural financial imperatives in an environment of upward pres- changes might be judged: do the changes enhance or sure on demand for services, and accountability concerns inhibit the system's ability to innovate? The requirement (in relation to quality and safety, and general good gov- for innovation and experimentation may not sit comfort- ernance), mostly in a highly political context. The review- ably with government requirements for standardisation of ers rightly sought to take a longer-term strategic known good practice. However in an area where best prac- perspective. They attempted (with varying degrees of suc- tice is not known, innovation is critical, and must be cess) to focus on good system design and capacity to meet supported. the broad and complex purposes of public health systems, recognizing the growing challenges the systems face. Unfortunately, the Commonwealth:state responsibility split, the one structural barrier most central to the sys- Structural reform is hardly ever evaluated, other than temic weakness of Australian primary care (and therefore when its weaknesses are articulated by those proposing most important for the capacity to develop and support the next round of changes, as part of the rationale for their new models of care for chronic diseases), is one that a efforts. There are many reasons for this failure, some of state can't address, at least not alone. The Productivity them political. One pertinent reason is that outcomes like Commission's recent call for an independent public containing the pressure of future growth in demand, or review of the whole health system [21], focused on over- improving health outcomes for the population, cannot be lapping roles and responsibilities for funding, offers judged within a realistic time frame. grounds to hope for movement in this otherwise intracta- ble problem. However, in the current environment, with strong conver- gence in the themes addressed by a fairly comprehensive The other pessimistic sign is the trend to more direct con- round of reviews of Australian health systems, an argu- trol of health care provision by state governments, related ment can be made for evaluation 'at the pointy end' of the no doubt to the twin problems of increasing demand (and changes. Given the challenges the reviews were intended therefore cost) and increasing disclosure of safety and to address, there are grounds to suggest that the current quality problems, both of which can only politicise the reforms will not succeed in achieving the stated (shorter- system more. Research on innovation, in relation to qual- and longer-term) goals unless they make a difference for ity and safety as well as other performance measures, indi- people with chronic illness. And if this is correct, the most cates that micro-management from above is not helpful useful immediate focus for evaluation of the success of the [22,23]. reforms may be their impact on the system's ability to develop and deliver better models of care for this growing Local evidence to support this view is scant. While the group of patients. effectiveness of the new arrangements during Queens- land's brief period of devolved governance was judged Methods harshly when it came time to re-centralise, some com- The 'data' for this project were the published reports of mentators suggest that this period also allowed Queens- systemic reviews of the health systems, and related land to catch up to other states in areas like accreditation, material published on departmental websites and in the casemix, IT and 'attention to performance management professional and academic literature. and outcomes' [24]. These sources were analysed to generate an understanding This may be a critical problem. While recognising that per- of the recommended governance authority structures; and spectives on this question are highly related to one's place the common themes emerging from the reasoning on in the structure, I would suggest that real innovation in which the recommendations were based. The themes Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:6 http://www.anzhealthpolicy.com/content/1/1/6 23. National Institute of Clinical Studies: Factors supporting high per- underpinning the recommendations were then assessed formance in health care organisations. Melbourne; 2003. in the light of the overarching goals of reform. 24. Surrao S, Taylor G, Turner A, Donald K: Hospital funding and services in Queensland. Aust Health Rev 2002, 25:99-120. Competing Interests I was a member of the South Australian 'Generational Health Review' Steering Committee, chaired its Govern- ance and Funding Task Force and continue to consult to the SA Department of Human Services. I worked for twenty years in health care agencies, and only one in a central health authority. References 1. NSW Department of Health: Planning Better Health: Back- ground Information July 2004. Sydney; 2004. 2. Generational Health Review: Better Choices Better Health: Final Report of the South Australian Generational Health Review. Adelaide: Government of South Australias; 2003. 3. Banscott Health Consulting: Report of the Review of the North- ern Territory Department of Health and Community Services. Darwin: Department of Health and Community Services; 4. Reid M, Daube M, Langonlant J, Saffioti R, Cloughan D: A healthy future for Western Australians: Report of the Health Reform Committee. Perth, W A Department of Health; 2004. 5. Reid M, and associates: ACT Health Review. Canberra: ACT Health Department; 2002. 6. Kibble and Associates: Victorian Public Hospital Governance Reform Panel Report. Melbourne, Victorian Department of Human Services; 2003. 7. Duckett SJ, Capp S, Carter M, Lowe E, Zimet A: Ministerial Review of Health Care Networks: Final Report. Melbourne: Victorian Department of Human Services; 2000. 8. Independent Pricing and Regulatory Tribunal of New South Wales: NSW Health: Focusing on patient care. Sydney; 2003. 9. Walker BW: Final Report of the Special Commission into Events at Campbelltown and Camden Hospitals. Sydney, NSW Department of Health; 2004. 10. Shannon E: Expert Advisory Group examine key issues for Tasmanian public and private hospital systems. Links Quarterly 2003:p.8. 11. Duckett S, Greeves P, Kinne L, Ratcliffe K: Hospital services in Tasmania. Aust Health Rev 2002, 26:141-155. 12. Somjen A: Distinguishing Features of Reform in Australia and New Zealand. In Health Reform in Australia and New Zealand Edited by: Bloom A. Melbourne: Oxford University Press; 2000:55-68. 13. Uhrig JA: Report of the Review of Metropolitan Hospital Administrative Arrangements and Responsibilities. Adelaide: Government of South Australia; 1986. 14. Taeuber K: Review of the Commission's Central Office. Adelaide: S A Health Commission; 1986. 15. South Australian Health Commission: Green Paper: Area Health Service Administration in South Australia. Adelaide, SA Health Commission; 1991. 16. South Australian Health Commission: The organisation of health services in South Australia: a response to the Discussion Paper (Green Paper) on Area Health Service Administra- Publish with Bio Med Central and every tion in South Australia. Adelaide; 1992. 17. South Australian Commission of Audit: Report of the S A Com- scientist can read your work free of charge mission of Audit. Adelaide, Government of South Australia; 1994. "BioMed Central will be the most significant development for 18. Australian Institute of Health and Welfare: Chronic diseases and disseminating the results of biomedical researc h in our lifetime." associated risk factors in Australia 2001. Canberra; 2002. 19. Australian Institute of Health and Welfare: Australia's Health Sir Paul Nurse, Cancer Research UK 2002. Canberra; 2002. Your research papers will be: 20. Department of Health and Aged Care: The Australian Coordi- nated Care Trials: Interim Technical National Evaluation available free of charge to the entire biomedical community Report. Canberra: Commonwealth of Australia; 2000. peer reviewed and published immediately upon acceptance 21. Productivity Commission: Review of National Competition Pol- icy Reforms: Draft Report. Canberra; 2004. cited in PubMed and archived on PubMed Central 22. Ferlie E B and Shortell SM: Improving the Quality of Health Care yours — you keep the copyright in the United Kingdon and the United States: A Framework for Change. The Milbank Quarterly 2001, 79:281 -315. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes)

Journal

Australia and New Zealand Health Policy – Springer Journals

Published: Nov 19, 2004

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