Re­forms must avoid familiar pit­falls

The Weekend Australian - Travel - - Health -

LESS than three months into its term, the Rudd La­bor Gov­ern­ment has made its mark on hospi­tal pol­icy in Aus­tralia. Soon af­ter the elec­tion came the an­nounce­ment of an ad­di­tional $600 mil­lion to be linked to pub­lic hos­pi­tals’ per­for­mance, in­clud­ing re­duc­ing wait­ing times for treat­ment. Last week Health Min­is­ter Ni­cola Roxon met state and ter­ri­tory health min­is­ters to dis­cuss per­for­mance stan­dards and how th­ese could be linked to hospi­tal fund­ing.

The Gov­ern­ment is also pro­gress­ing its pre­elec­tion pol­icy to es­tab­lish a na­tional health and hos­pi­tals re­form com­mis­sion to in­form and over­see pol­icy changes across the spec­trum of the health sys­tem.

The Aus­tralian Health­care and Hos­pi­tals As­so­ci­a­tion (AHHA) wel­comes the ad­di­tional re­sources for pub­lic hos­pi­tals and the Gov­ern­ment’s fo­cus on end­ing the blame game’’ be­tween fed­eral and state/ter­ri­tory gov­ern­ments in health care. This re­flects the pol­icy of AHHA, along with other health groups, and should help achieve a more in­te­grated and co­or­di­nated approach to health care.

Con­sumers should also wel­come this fo­cused and for­ward-think­ing pol­icy agenda from the fed­eral Gov­ern­ment. If suc­cess­ful, it will help de­liver the high qual­ity and ef­fi­cient pub­lic hospi­tal sys­tem that Aus­tralia de­serves.

How­ever, trans­lat­ing poli­cies into ac­tion will be a chal­lenge. As gov­ern­ments in other coun­tries have found when they have tried to im­prove hos­pi­tals’ per­for­mance in ar­eas such as wait­ing times for treat­ment, it is easy to make mis­takes. Ini­tia­tives which look good on pa­per can back­fire when put into prac­tice, leav­ing peo­ple no bet­ter off and cost­ing the com­mu­nity sig­nif­i­cant amounts of money.

Avoid­ing th­ese mis­takes re­quires a sound un­der­stand­ing of the com­plex­ity of the hospi­tal sys­tem. This is why it is vi­tal that the fed­eral Gov­ern­ment learns from the ex­pe­ri­ence of peo­ple who know how the hospi­tal sys­tem works, and closely in­volves the hospi­tal sec­tor in de­vel­op­ing strate­gies to in­crease com­mu­nity ac­cess to care.

AHHA sup­ports in­creas­ing ac­count­abil­ity and trans­parency of hospi­tal fund­ing, but the way in which this is achieved is cru­cial. Some com­mon pit­falls to avoid in­volve set­ting crude tar­gets for out­comes, such as wait­ing list re­duc­tion. This could re­sult in gam­ing’’ (ar­ti­fi­cial low­er­ing of wait­ing lists) through, for ex­am­ple, chang­ing the way in which records are kept for peo­ple wait­ing for surgery. This could de­liver re­duc­tions on pa­per, with­out re­sult­ing in any ad­di­tional ser­vices to pa­tients.

Re­duc­ing wait­ing times for treat­ment can also have the un­in­tended con­se­quence of in­creas­ing de­mand as peo­ple move from the private back to the pub­lic sys­tem. This will have the ef­fect of in­creas­ing wait­ing times again, de­spite the fact that many peo­ple pre­vi­ously on the wait­ing list have re­ceived care. It may also re­sult in a less eq­ui­table out­come for peo­ple who do not have the re­sources to seek care in the private sys­tem, as they may be al­lo­cated a lower place on the wait­ing list due to the in­creased de­mand.

Tar­gets for re­duc­ing wait­ing list times also need to take into ac­count that some­times there are valid rea­sons for wait­ing pe­ri­ods. For ex­am­ple, some­one who is obese may need to lose weight be­fore surgery can be safely per­formed. If hos­pi­tals are given in­cen­tives to re­duce av­er­age wait­ing times for treat­ment, it may cre­ate pres­sure for them to op­er­ate on peo­ple ear­lier than is op­ti­mum.

Any in­cen­tives pro­vided to hos­pi­tals to im­prove per­for­mance need to be care­fully con­sid­ered to en­sure they do not cre­ate a con­flict be­tween hospi­tal and pa­tient in­ter­ests. A sim­plis­tic approach to tar­get set­ting has of­ten de­liv­ered good re­sults in the area un­der scru­tiny, but has had un­fore­seen ad­verse con­se­quences for other re­lated parts of the health sys­tem.

For ex­am­ple, it was re­ported re­cently that UK hos­pi­tals were re­spond­ing to in­cen­tives for wait­ing list re­duc­tion by fo­cus­ing on rel­a­tively straight­for­ward op­er­a­tions, such as cataract ex­trac­tion, at the ex­pense of more com­plex pro­ce­dures. The re­sult has been that peo­ple with very mi­nor cataract prob­lems — in­clud­ing some whose vi­sion re­duc­tion is so mi­nor they can still drive — are be­ing of­fered cataract ex­trac­tions, while peo­ple with sig­nif­i­cant dis­abil­i­ties (re­quir­ing more com­pli­cated pro­ce­dures) re­main on the wait­ing lists.

En­sur­ing that a fo­cus on qual­ity and safety of pa­tient care is at the cen­tre of any new ini­tia­tives is the key to the suc­cess­ful im­ple­men­ta­tion of the Gov­ern­ment’s hospi­tal and broader health­care pol­icy agenda.

Avoid­ing the mis­takes ex­pe­ri­enced by other coun­tries will re­quire an un­prece­dented level of col­lab­o­ra­tion be­tween fed­eral and state/ ter­ri­tory gov­ern­ments as well as the close in­volve­ment of the pub­lic hospi­tal sec­tor and health pro­fes­sion­als.

Es­tab­lish­ing close links be­tween the na­tional health and hos­pi­tals re­form com­mis­sion and the Aus­tralian Coun­cil for Safety and Qual­ity in Health Care will be es­sen­tial, as will be on­go­ing in­put from con­sumers at all lev­els.

Given the wide­spread work­force short­ages af­fect­ing all ar­eas of the health sys­tem, it is also im­por­tant that we do not place un­due de­mands on ex­ist­ing health pro­fes­sion­als. Hos­pi­tals can only in­crease their ac­tiv­i­ties to the ex­tent that they have the phys­i­cal and work­force ca­pac­ity to do so. Qual­ity of care should not be com­pro­mised by plac­ing in­creased stress and pres­sure on hospi­tal staff to work at an un­re­al­is­tic level.

AHHA is con­fi­dent that if th­ese rec­om­men­da­tions are fol­lowed, the chal­lenges of im­ple­ment­ing health sys­tem re­form can be met.

We wel­come the progress al­ready made by the Rudd Gov­ern­ment in driv­ing its health pol­icy agenda and we look for­ward to work­ing with the min­is­ter and her de­part­ment, along with state and ter­ri­tory gov­ern­ments, to de­liver a stronger and safer hospi­tal and health care sys­tem for all Aus­tralians. Prue Power is ex­ec­u­tive di­rec­tor of the Aus­tralian Health­care and Hos­pi­tals As­so­ci­a­tion

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