The Nature and Culture of Health Care

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Contents

The Australian Health Sector

It is not the purpose of this Section to provide a summary of the Australian Health System but rather to point to some quality reference material which those students who feel the need to update their current knowledge. It is assumed other units will provide much more detail in this general area.

  • The best current review of the operations and performance of the Australian Health System at a macro level is found in Chapter One of the Final Report of the Health and Hospitals Reform Commission which was released in 2009.

This can be downloaded from this link. (Accessed September 2012). This chapter needs to be reviewed carefully as it provides context for the current reform directions. The full report is also vital reading to understand the present more general reform plans. It can be downloaded from this link.

  • For those needing detailed information on particular aspects of the Australian Health System the Australian Institute Of Health and Welfare (AIHW) produces two bi-annual reports containing an absolute wealth of information which will be useful for all those attempting the overall course and not only this specific unit. They are:

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'Australia's health 2012' is the thirteenth biennial health report of the Australian Institute of Health and Welfare. It is the most comprehensive and authoritative source of national information on health in Australia. It provides answers to questions such as: - How healthy are Australians? - What major milestones affect health over the life course? - How can we protect and promote good health? - What are the major causes of illness? - How do we treat people who are sick? - Where do our health dollars come from and where do they go? - Who works in health? - What is being done to find out more about our health? ISSN 1032-6138; ISBN 978-1-74249-305-3; Cat. no. AUS 156; 628pp.; $60 , and

Expenditure on health in Australia was estimated to be $130.3 billion in 2010-11, up from $77.5 billion in 2000-01. This expenditure was 9.3% of gross domestic product in 2010-11, down from 9.4% in 2009-10 but up from 8.2% in 2000-01. The estimated recurrent expenditure on health was $5,796 per person, and 69.1% was funded by governments, up from 67.7% in 2000-01. The two largest components of the increase in health expenditure were public hospital services, which grew by $2.2 billion in real terms, followed by medications ($2.1 billion). ISSN 1323-5850; ISBN 978-1-74249-350-3; Cat. no. HWE 56; 183pp.; $33

  • A recent comparison of Australia with other health systems is International Profiles of Health Care Systems, S. Thomson, R. Osborn, D. Squires, and M. Jun,The Commonwealth Fund, November 2012. Available here PDF file [112p.]
  • The most authoritative book on the topic is the following:

The Australian Health Care System By Stephen Duckett, Sharon Willcox Format: Paperback, 388 pages, 4th Revised edition Edition Published In: Australia, 30 June 2011 The Australian Health Care System 4E provides students with a comprehensive and forward-looking overview of the structure and operation of health systems and services in Australia. It analyses how the inputs of Australian health services, such as finances, the health workforce, and the roles of state and federal government, influence the outcomes, which range from consumer confidence to policy changes. Written with an emphasis on policy and economic issues, the book provides an extensive overview of the interactions between consumers and providers of health care in Australia. It includes expanded coverage of Primary Care, Specialist Health Services, Aged Care and Disability Services and increased pedagogy, such as case studies of sections of the health care system. Table of Contents 1. Frameworks for Analysis 2. The Australian Population and its Health 3. Financing Health Care 4. The Health Workforce 5. Governance, Accountability and Reform 6. Public Health 7. Primary Health Care Services 8. Hospitals 9. Specialised Health Services 10. Pharmaceuticals 11. Aged care and Disability Services 12. Policy Challenges for the Australian Health Care System Appendices Appendix 1: Funding flows for hospital and medical services, Australia Appendix 2: Evolution of Medicare/Health insurance arrangements Publisher: OUP Australia and New Zealand ISBN: 0195574648 EAN: 9780195574647 Dimensions: 25.0 x 19.0 x 1.0 centimeters (0.62 kg) The book is available in the ACU Library (no e-book) or can be obtained from this link.

  • A graphic from the AIHW Australia's Health 2012 Fig 1.4 p17 shows the complexity of the overall system and the disparate sources of funding involved.

Addressing this fragmentation (and blame shifting / finger pointing) was a key objective of National Health Reform. To date however most changes have been less that totally effective in reaching the objective. Section 1.4 of Australia’s Health 2012 (cited above) provides an excellent summary of the Health System as it presently is. In response to the initial and final reports of the National Health and Hospitals Reform Commission the Government has issued a series of responses. The key diagnostic section on what was wrong with the system identified the following issues (Page 3 and following):

Problems with our Health System Today

A system that isn’t prepared for future challenges

While Australia’s health system serves most Australians well, at a cost to the community that is around the average of other advanced nations, it is facing a number of serious challenges:

  • An ageing population will substantially increase both health care needs and expenditure, while further constraining our health workforce. The 2010 Intergenerational Report forecasts the proportion of our population aged over 65 will increase from 14 per cent in 2010 to 23 per cent by 2050.
  • Our population is projected to grow from 22 million people today to 36 million by 2050. This growth will create the need for more health services, new investment in health infrastructure and an expanded health workforce.
  • Chronic disease is a large and increasing burden on our health system. For example, the cost of type two diabetes is projected to increase by more than 520 per cent from 2002–03 to 2032–33.
  • Costs have increased sharply in recent years and are expected to continue growing. The 2010 Intergenerational Report projects health costs to increase from 15 per cent of all Commonwealth Government spending now (4.0 per cent of GDP) to 26 per cent by 2050 (7.1 per cent of GDP).
  • Workforce shortages are already placing limitations on the delivery of health care — particularly in regional and rural Australia. As well as training more health professionals, we will need to be more effective at making the most of the skills and dedication of our existing health workforce.

Too much blame and fragmentation between governments

In effect, Australia currently has eight different state and territory health systems. The distribution of responsibilities for health between different levels of government is blurred and unclear, resulting in duplication, cost‑shifting and blame‑shifting. The relative financial contributions of different levels of government to hospital services are fiercely disputed, especially when hospital funding arrangements are negotiated. Further, patients find it hard to work out which level of government is accountable for their care, when all they want is the services they need. Clear boundaries need to be set between the responsibilities of each level of government, and services designed accordingly.

Gaps and poor coordination in health services that people need

Too many patients are either falling through the gaps or receiving uncoordinated care. Changes that streamline the delivery of care and remove fragmentation in services are long overdue, particularly for people living with chronic disease. In addition, not all Australians get the services they need. People living in rural and regional areas, for example, sometimes struggle to access primary health care. Many people are unable to access out of hours GP services. Some groups in our community, such as Indigenous Australians and those living in highly disadvantaged areas, have poor health outcomes, and are unable to access appropriate care.

Too much pressure on public hospitals and health professionals

Our public hospital system is struggling to cope with growing patient demand and stretched budgets. For more than half a decade, almost one in six elective surgery patients and one in three people attending emergency departments have been waiting longer than the recommended time for treatment. Australia’s rates of hospital admission are above the Organisation for Economic Cooperation and Development (OECD) average and significantly higher than comparable countries such as the United States, New Zealand, and Canada. This pressure and constant strain on resources is also felt in the everyday working lives of health professionals. These problems are not likely to be resolved through incremental funding and policy changes. New arrangements that fundamentally change the way hospitals are funded and run are needed to ensure additional hospital capacity, greater efficiency, and better services.

An unsustainable funding model

The cost of providing health care is expected to continue to increase into the future. But state government revenue growth is not keeping pace with growing health care costs. In the five years to 2007–08, public hospital expenditure has grown at an average of close to ten per cent per year. Projections show that by 2045–46, health spending alone would be more than all revenue collected by state and local governments — and that in some states, this will happen earlier. Strong action is needed to ensure the sustainability of health care funding.

Too much inefficiency and waste

Waste and inefficiency are ongoing challenges for the health system. The Productivity Commission estimates that some public hospitals may be running up to 20 per cent less efficiently than best practice. Costs per patient vary between state public hospital systems, suggesting efficiency in some states is better than in others. The Commonwealth Government currently funds states with block grants for public hospital services. Despite recent improvements through the National Healthcare Agreement, the transparency of health care funding and spending is still relatively limited. This lack of transparency means taxpayers and the governments that serve them are unable to make robust comparisons across states, or easily identify where there is inefficiency. Part of the problem is overly centralised and bureaucratic administrative arrangements for hospitals in some states, which sap the innovation and drive of local clinicians and managers, and reduce incentives to improve performance.

Not enough local or clinical engagement

Many clinicians and citizens are not adequately involved in decisions about the delivery of health services in their local community. Current arrangements fail to make the most of the expertise and commitment of our clinical workforce. It also means that some services are poorly tailored to community needs. Decisions made at a local level, with appropriate clinician and community engagement concerning service mix and delivery options, can bring significant improvements in both productivity and service quality.

Recent Attempts At Reform of The Health Sector

The reference is as follows: A National Health And Hospitals Network For Australia’s Future ISBN: 978-1-74241-147-7 Online ISBN: 978-1-74241-148-4 Publications Number: P3-6430 This is found here This is a useful list as just how effective the present reforms have been can reasonably be assessed on just how effectively each of these areas have been addressed. Here is the key page that describes what is being done in this context as of late 2012.

Here is the top level Summary: About National Health Reform Australia’s health system is amongst the best in the world. However, demands on the system are increasing due to an ageing population, increased rates of chronic and preventable disease, new treatments becoming available and rising health care costs.

Working in partnership with states and territories, the Australian Government has taken action to address these challenges and in August 2011, secured a truly national agreement that will deliver the funding public hospitals need, with unprecedented levels of transparency and accountability, less waste and less waiting for patients.

Key components of the National Health Reform Agreement (and the related National Partnership Agreement on Improving Public Hospital Services and the National Healthcare Agreement 2011) that are directing the changes to Australia’s health system include:

  • a new framework for funding public hospitals and an investment of an additional $19.8 billion in public hospital services over this decade;
  • a focus on reducing emergency department and elective surgery waiting times;
  • increased transparency and accountability across the health and aged care system;
  • a stronger primary care system supported by joint planning with states and territories and the establishment of Medicare Locals; and
  • the Australian Government taking full policy and funding responsibility for aged care services, including the transfer to the Australian Government of current resourcing for aged care services from the Home and Community Care (HACC) program, in most states and territories except Victoria and Western Australia.

End Extract.

To date the reform journey has largely been characterised by the Department of Health ‘cherry-picking’ some elements of the NHHRC Report and largely ignoring many others. The other important point to realise is that as of the end of 2012 all the machinery for delivery of the planned reforms is either still not operational or is very new. It is unlikely the impact of the Reforms will be felt in any concrete way in the next year or so - and of course many of the changes that don’t have bi-partisan support as we have a Federal Election due in the next 12 months where a change of government presently seems quite likely. No matter what happens it will be many years before it becomes clear just how effective the proposed reforms have been in practice. That said all students should review the web site closely to understand just what is planned.

The National E-Health Strategy

In 2008 Deloittes (A major consulting firm) was commissioned to develop a National E-Health Strategy for Australia. The work was requested by the Australian Health Ministers Council (AHMC) - which is a part of the Council of Australian Governments (COAG) framework. You can download a copy of the Strategy Document from this page Sadly, while COAG agreed and approved the National Strategy implementation as a coherent strategy as not funded and instead - despite claims from Government suggesting it was following the strategy - we saw funding of the Personally Controlled E-Health Record Program in the 2010 budget. The failure to take the approach recommended in the National Strategy has led to a range of issues and problems that will be explored during this course. It is expected that students completing this unit will have a high level understanding of the proposed National Strategy and the rationale behind its recommendations.

Health Sector Culture

While hard to explicitly pin down there is a sense that the nature and responsibilities associated with the delivery of health care drives a workplace culture in the sector (at the coal-face of care delivery) which is different from other workplaces. Some aspects of this culture are important when considering the operations of the sector, especially as this is related to the use of and interaction with technology. Aspects of the culture that may be relevant include:

  • Conservatism - because much of what is done in the delivery of care has not changed over a long period sticking with the ‘tried and true’ seems both safe and sensible.
  • An understanding of hierarchy and the associated responsibilities. While there is a culture of ‘team work’ clearly needed and indeed in evidence in most settings there is also a need to decisions to be taken when required.
  • Separate and somewhat distinct cultures for each professional group also exist (nursing, medical and so on) and it is noticeable that the further away an individual’s role is from direct patient care the less traditional caring values are in evidence (e.g. clinical and nursing working hours are often very flexible and have a ‘till the job is done’ attitude which does not exist in say the accounting staff).
  • Clinical workplaces are typically environments where patient privacy is carefully protected and where preservation of patient dignity and autonomy is seen as important.
  • A sense of individual accountability for patient outcomes and especially for errors that may have harmed a patient.
  • A lack of sensitivity to cost. What a patient is seen by the carer to need will be provided if at all possible - even though, on occasion, the evidence backing a choice may be lacking.
  • An appreciation of the tenets of the Hippocratic Oath and observance of the general spirit embodied therein.

See here for a range of texts of said oath:

These attitudes can feed into how change management and technology implementation are approached.

Change Management in the Health Sector

As outlined in an earlier section the Australian Health Sector faces a number of what may be termed ‘challenges’. A short list of the key ones include:

Key Challenges

  • The Ageing Population.
  • Workforce shortages and ageing.
  • Remorseless rises in Healthcare costs above inflation leading to financial sustainability issues.
  • A continuing inability to allocate clear lines of funding responsibility with inevitable political bickering, blame-shifting and waste.
  • Rising cynicism and alienation within the workforce with a loss of some value-driven behaviours (as cited above)
  • Work-practices which remain arguably much too provider centric rather than consumer / patient centric.
  • Continuing very slow diffusion of evidence based practice approaches into the clinical community.
  • Continuing inability to measure much in the way of clinical outcome and patient satisfaction information.
  • Many professional staff feeling the effects of what are felt to be excessive work pressures and bureaucracy.

Taking the mixture of the culture described above and the issues identified in this section it is clear that any significant change - technology based or not - is going to face considerable resistance and if change is to be successfully implemented then considerable careful planning is needed.

Specific considerations in health sector change management

These also need to be considered:

  • Often the thought leaders are both highly opinionated, highly competent (at least in a narrow field) and typically influential on those they work with on teams.
  • Impact and quality and safety of patient care is much more highly valued that efficiency and cost saving.
  • Many of the hospital workforce and virtually all the non-hospital workforce are independent practitioners who are not responsive to command and control - need incentives, carrots, explanation and intelligent justification of change.
  • At least some any change will need to convince have highly developed ‘bull____ detectors’ and are pretty smart and cynical to boot - so are often a very, very hard sell.
  • The risk / reward ratio of making any change needs to be apparent and easily understood and possible and or potential issues identified up front rather than hoping no-one will notice.

In summary change management in the sector can be very difficult and needs a high level of cultural awareness as well as a sound considered approach. The Wikipedia article on Change Management provides some useful general background.

Additional Key Resource

For those who feel additional information in the ‘Nature of Healthcare’ domain there is a useful unit in the US Developed Health IT Course which has been developed by 5 major universities for the Office of the National Co-ordinator For Health IT (ONCHIT). These are provided free - following registration - from the National Training and Dissemination Center. The website is found here: Of particular relevance to the discussion in this section is Component 2. The Culture of Healthcare “For individuals not familiar with healthcare, this course addresses job expectations in healthcare settings. It will discuss how care is organized inside a practice setting, privacy laws, and professional and ethical issues encountered in the workplace. “ The learning objectives explain the contents of the component:

Component Objectives

At the completion of this component, the student will be able to:

  • Describe the major types of clinical personnel involved in healthcare, including their education and training, certification and licensure, and typical roles in healthcare.
  • Describe the major types of settings in which healthcare occurs including ambulatory care, acute and emergency care, hospital based and critical care, and community health and public health settings.
  • Describe the major processes of information gathering, analysis, and documentation used by clinicians to detect, understand, and prevent or treat diseases.
  • Give examples and explain the differences between common forms of care delivery including episodic one-on-one care, multidisciplinary care, interdisciplinary care, care of chronic conditions, population based care, disease management, long-term care, and end of life care.
  • Describe the role of community health and public health in managing illness outbreaks, epidemics, and pandemics.
  • Understand the basic principles of evidence-based practice, including the application of the best evidence in clinical decision-making.
  • Describe common forms of quality measurement, performance improvement, and incentive payment schemes meant to influence care delivery.
  • Discuss the role of medical ethics and professional values in care delivery including such issues as ethical conflicts, and health disparities.
  • Understand the concepts underlying the application of privacy, confidentiality, and security to health care practice and information technology, being able to help individuals and organizations adhere to the HIPAA Privacy and Security Rules.

Units 8, 9 and 10 are particularly recommended for review. For those undertaking the program from a non-health background all the material in this component should be reviewed.

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