Re­form needs to re­fo­cus on re­search

The Weekend Australian - Travel - - Health -

THE Rudd Gov­ern­ment’s com­mit­ment to a ma­jor re­view of Aus­tralian health ser­vices, with a Na­tional Health and Hos­pi­tals Re­form Com­mis­sion, be­fore re­solv­ing the long-term re­spon­si­bil­ity for hos­pi­tals, is wel­comed.

The cur­rent struc­ture, with shared re­spon­si­bil­i­ties for fund­ing of hos­pi­tals be­tween Com­mon­wealth and the States, was set in place with in­tro­duc­tion of Med­ibank in 1975. Many is­sues have changed in the in­ter­ven­ing 33 years, both in health ser­vices and com­mu­nity needs.

The cur­rent tan­gled and con­flict­ing re­spon­si­bil­i­ties for the sick el­derly are not the an­swer. Health care for the aged needs case man­age­ment cross­ing hospi­tal, nurs­ing home and com­mu­nity sec­tors. The Coun­cil of Aus­tralian Gov­ern­ments (COAG) sees di­a­betes and obe­sity as ma­jor chal­lenges, but con­flict­ing re­spon­si­bil­i­ties need a re­think if head­way is to be achieved. There are many emerg­ing is­sues im­pact­ing on both hospi­tal and pri­mary care ser­vices and on pre­ven­tion.

Ini­tia­tives have been taken re­lated to safety and qual­ity in hos­pi­tals, such as de­vel­op­ment of the Aus­tralian Coun­cil on Safety and Qual­ity in Health Care and the Na­tional In­sti­tute of Clin­i­cal Stud­ies, but to date th­ese have had lim­ited im­pact. Our na­tional sys­tem, ar­tic­u­lated through the Aus­tralian Health Care Agree­ments (AHCAs), has bud­gets, pa­tient through­put fig­ures and wait­ing lists as the pri­mary driv­ers in hos­pi­tals man­age­ment.

Dur­ing the re­cent elec­tion cam­paign, states were crit­i­cised for poor man­age­ment of hos­pi­tals, but we have no real ev­i­dence on which to as­sess qual­ity of per­for­mance. In re­cent years, in the UK’s Na­tional Health Ser­vice (NHS) and many hospi­tal ser­vices in the US, mea­sures of hospi­tal per­for­mance have be­come widely em­ployed, with in­ter­na­tional bench­marks, such as those de­vel­oped by the US Com­mon­wealth Fund.

There is now clear ev­i­dence that qual­ity of health care has sig­nif­i­cantly im­proved in the NHS since such mea­sures have been used. Qual­ity of per­for­mance of re­search-ac­tive (teach­ing) hos­pi­tals has been shown to be su­pe­rior to that of non-teach­ing hos­pi­tals. There are many rea­sons for this, in­clud­ing at­tract­ing and re­tain­ing staff of high qual­ity, com­mit­ment to in­no­va­tion and to con­stant as­sess­ment of the qual­ity of out­comes.

When ma­jor in­no­va­tion in health ser­vices is be­com­ing pos­si­ble with dis­cov­er­ies in biomolec­u­lar medicine and with in­no­va­tive use of in­for­ma­tion tech­nol­ogy, we must en­sure we have the ca­pac­ity to re­spond. It is es­sen­tial that we have, for the fu­ture, a ba­sis for in­no­va­tion and de­vel­op­ment in our na­tional sys­tem.

In the UK this has been tack­led with changes, cul­mi­nat­ing in the Cook­sey Re­port of 2006, mak­ing re­search and de­vel­op­ment in­te­gral com­po­nents of the func­tion of all ma­jor hos­pi­tals. In the US, ma­jor univer­sity hos­pi­tals, since the Flexner Re­port of 1910, have had a com­mit­ment to re­search and have been the source of many ma­jor ad­vances in medicine and surgery in­ter­na­tion­ally over the past 40 years. In Aus­tralia, with a hospi­tal sys­tem un­der fi­nan­cial stress and no mea­sures of qual­ity as­so­ci­ated with fund­ing or con­trol, re­search has in­creas­ingly been seen as a cost, not rel­e­vant to per­for­mance of hos­pi­tals or of their CEOs. In­ci­dents such as a mis­car­riage in an emer­gency de­part­ment come to be used as a mea­sure of hospi­tal qual­ity!

The ab­sence of any ma­jor com­mit­ment to re­search and de­vel­op­ment in health ser­vices or of for­mal as­sess­ment of qual­ity of out­comes has long-term health sys­tem.

We have strong med­i­cal re­search in Aus­tralia, but its pres­ence as a nec­es­sary func­tion of hos­pi­tals is in jeop­ardy. The sit­u­a­tion is made worse when re­search funds, nor­mally from NHMRC and ma­jor al­ter­na­tive bod­ies, pass pri­mar­ily through univer­si­ties or med­i­cal re­search in­sti­tutes, which then re­ceive Com­mon­wealth re­search in­fra­struc­ture fund­ing. Hos­pi­tals, how­ever, re­main re­spon­si­ble for Hu­man Re­search Ethics ap­proval and all re­search re­lated to pa­tient care must be ap­proved by the hospi­tal — but there is no source of fund­ing for ad­min­is­tra­tion and sup­port of this func­tion.

im­pli­ca­tions

for

Aus­tralia’s

Trans­la­tional re­search’’ is the means by which new meth­ods to de­liver health care emerge from ad­vances in science and tech­nol­ogy, but the in­cen­tive in man­ag­ing hos­pi­tals is to min­imise ex­pen­di­ture on ac­tiv­i­ties not di­rectly re­lated to pa­tient through­put, wait­ing lists and bal­anced bud­gets.

Ap­point­ment of hospi­tal re­search direc­tors and sup­port staff are in jeop­ardy un­less sup­port of re­search and de­vel­op­ment be­comes recog­nised as of ma­jor sig­nif­i­cance in the per­for­mance of hos­pi­tals, linked with ap­pro­pri­ate fund­ing. The com­mit­ment to con­tin­u­ing re­view of clin­i­cal out­comes for pa­tients, so fun­da­men­tal to ap­plied clin­i­cal re­search, is also ba­sic for data col­lec­tion on qual­ity of hospi­tal per­for­mance.

Pro­fes­sor Sally Davies, di­rec­tor-gen­eral for re­search and de­vel­op­ment for the NHS, will be in Melbourne on 30 Jan­uary 2008 in as­so­ci­a­tion with a re­view of the NHMRC. A na­tional sum­mit will be held at which CEOs of a num­ber of ma­jor teach­ing hos­pi­tals around Aus­tralia will meet her to learn from Bri­tish ex­pe­ri­ence. It is pro­posed to de­velop a plan for sup­port of the re­search func­tion of ma­jor hos­pi­tals in Aus­tralia, which might then be in­cor­po­rated in fu­ture AHCA ar­range­ments. Pro­fes­sor David Pen­ing­ton AC was chair­man of the Com­mon­wealth Com­mit­tee of In­quiry into Rights of Private Prac­tice in Pub­lic Hos­pi­tals in 1984, which en­tailed re­view­ing the en­tire Aus­tralian pub­lic hospi­tal sys­tem. He has since been vice-chan­cel­lor of the Univer­sity of Melbourne.

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