HEALTH MATTERS Victorian Healthcare Association ISSUE 1
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MAY 2014
] vha.org.au
Governance award winner multiple accreditation philanthropic funding elective surgery access 1
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CHAIRMAN’S MESSAGE Governance tool for board evaluation and benchmarking CHIEF EXECUTIVE’S MESSAGE Time to evolve our model of devolved governance QUALITY & SAFETY Streamlining accreditation to reduce administrative burden
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How philanthropy can fund innovative health projects
AUSTRALIAN CENTRE FOR HEALTHCARE GOVERNANCE 2014 Governance Excellence Award MERCY HEALTH FOUNDATION How philanthropy can fund innovative health projects ADVOCACY HEALTH ALLIANCES Health-legal partnerships help vulnerable populations ADVOCACY HEALTH ALLIANCES Bendigo pilot aims to break the cycle of disadvantage AGED CARE READINESS PROJECT Aged care reforms: an opportunity in change ELECTIVE SURGERY ACCESS Elective surgery waiting lists: busting the myths DISASTER RESPONSE & RECOVERY Community health services continue their recovery role five years after Black Saturday
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Busting the myths of elective surgery waiting lists
For editorial content please contact: SARA BYERS Media and Communications Manager The Victorian Healthcare Association Level 6, 136 Exhibition Street Melbourne, Victoria 3000 Australia Telephone: +61 3 9094 7777 Facsimile: +61 3 9094 7788 Email: vha@vha.org.au www.vha.org.au The VHA would like to thank member agencies and supporters for supplying many of the photos included in this edition. This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior permission from The Victorian Healthcare Association and inquiries concerning reproduction and rights should be addressed to the editor. © The Victorian Healthcare Association Ltd 2014.
The Victorian Healthcare Association (VHA) is the major peak body representing the interests of the public healthcare sector in Victoria. Our members are public hospitals, rural and regional health services, community health services and aged care facilities. Established since 1938, the VHA promotes the improvement of health outcomes for all Victorians, from the perspective of its members. Cover image: Victorian Minister for Health, David Davis, presents the ACHG Governance Excellence Award to Yvonne Wrigglesworth and Marilyn Forde of Whitehorse Community Health Service.
This publication is printed using eco-clean print processes by Southern Colour (Vic) ISO9001 / ISO14001 & AS/NZS 4801
ANTHONY GRAHAM VHA CHAIRMAN
Chairman’s Message
“The evaluator has been extensively upgraded to ensure it meets the needs of all our registered and potential users. This one-stop online tool allows directors to undertake a board selfassessment across nine key governance areas.”
Governance tool for board evaluation and benchmarking The governance work of the Victorian Healthcare Association and the Australian Centre of Healthcare Governance has gained significant momentum over the past 12 months. The profile of the ACHG has been intentionally raised at a time when politicians, policy-makers and the health sector are showing an increased appetite for governance knowledge and process. The ACHG launched its Governance Evaluator – an affordable online evaluation and development tool for directors and boards – in early 2013. A year on, the evaluator has been extensively upgraded to ensure it meets the needs of all our registered and potential users. This one-stop online tool allows directors to undertake a board selfassessment across nine key governance areas. Once an evaluation is completed, the tool generates a governance capability assessment highlighting the board’s level of maturity across the nine domains. It also provides an action plan with recommendations for further board development, and resource manuals containing model policies, procedures, templates and facts sheets. By making this uniform survey available to the sector, the ACHG will be able to collect data to establish benchmarks which can be used to inform the sectorwide development of boards. Healthcare agencies can also use this data to benchmark their own board performance against that of similar organisations.
We were delighted to have the Minister for Health, David Davis, join our conference panel discussion to give his perspective on the current state of healthcare governance in Victoria. Minister Davis also presented the 2014 ACHG Governance Excellence Award to our inaugural winner, Whitehorse Community Health Service. This award showcased outstanding contributions to strengthening the governance of publiclyfunded health and community services. Whitehorse Community Health Service has developed and embedded quarterly organisational goals to measure performance and accountability using a traffic light system. This approach kept the board informed of organisational performance against its strategic objectives and kept the planning cycle transparent and realistic, with timely reporting. I congratulate Whitehorse Community Health Service and our other finalists – Cobaw Community Health, West Gippsland Healthcare Group, Bendigo Healthcare Group and the Royal Women’s Hospital. I hope you enjoy reading their stories and other public healthcare news in the following pages.
The self-assessment board evaluation design is based on good governance principles as outlined in the ASX Corporate Governance Principles and Recommendations (ASX 2007). The methodology is consistent with guidelines in the Australian Institute of Company Directors: Evaluating Board Performance: A guide for company directors (AICD 2006). For further information on the Governance Evaluator please visit healthcaregovernance.org.au
The ACHG conference Devolution, Evolution or Revolution? The Future of Devolved Governance in Health was held on May 15-16 and provided an opportunity for discussion on the progress and outcomes of the Governance Evaluator thus far.
The Victorian Healthcare Association Issue 1 [MAY 2014] vha.org.au
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Chief Executive’s Message
Time to evolve our model of devolved governance
TREVOR CARR VHA CHIEF EXECUTIVE
of healthcare delivery amplify this challenge, so without incentives we are unlikely to take on the risk of change.
The VHA believes the centrepiece of Victoria’s public healthcare system – our devolved governance model – is overdue for significant evolution. Our hospitals, health services and community health services have a long history of selfdetermination, with the current iteration of our model adopted through the Health Services Act of 1988. The VHA believes it is time for our devolved governance model to evolve further, in order to meet the challenges of the 21st century. This will require the development of measurable governance KPIs to give politicians and policy-makers sufficient confidence to embrace the change in exposure to risk that will result from further devolution. So what do we believe needs to be fixed? Our current model lacks incentives for the business of healthcare to change. Change in any business environment is hard and carries risk. The complexities
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What needs to change? There is general acceptance that a gradual shift away from bed-based services to care within home and community settings is necessary. There is also a growing level of support for skills-based carer models, as opposed to profession-based models, as long as this can be achieved while maintaining clinical safety. However, funding models that reward particular approaches to care, and the industrial and professional demarcation of roles, are barriers to this type of change. A well-known requirement of any director is to understand the business you are in. The business of healthcare governance is, by definition, the business of clinical service provision. To this end, research conducted by the University of Melbourne (and jointly commissioned by the VHA and the VMIA) has shown that clinical governance practice is highly variable across Victoria and that boards themselves recognise the need for skills development in this area. Further devolution would need to be coupled with developing and strengthening boards to take up the challenge of greater autonomy. Importantly, our current model does not devolve control of capital and strategy to the board table. In the absence of responsibility for such fundamental elements of governance, boards have little option but to focus on the operational strengths and weaknesses of their organisations. The VHA believes reform is necessary to ensure that boards are able to focus on the strategic governance of their organisations.
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So how do we convince our policy leaders to further evolve our model of devolved governance? Any further devolution is going to need careful assessment of the relative risks for politicians, bureaucrats, healthcare directors (personally), unions, funders, and the community. To mitigate these risks, metrics must be developed to assess the readiness of each healthcare board to operate more autonomously than current arrangements provide. Such metrics could reasonably be expected to include: the board approach to clinical governance; alignment between services provided (bed-based and nonbed based) and population health needs; threshold levels of staff satisfaction supported by high retention and low absenteeism; consumer engagement and budget performance. Upon meeting these metrics, services could prove to government and the community that they are worthy of further autonomy. Funding models would need to shift towards providing incentives for boards to evolve. Longer term (three-year) funding arrangements and a capacity to bank both direct savings and indirect broader economic savings must be part of this equation. Victoria has a proud history of local governance – at arm’s length from government and responsive to local needs. The growing challenges facing our healthcare system mean the time is right to evolve our system of devolution to the next level. The challenge of managing public expectations is a constant, which will continue to feed change within our system for many years to come.
Streamlining accreditation to reduce administrative burden
SARA BYERS EDITOR HEALTH MATTERS
Quality & Safety
Rigorous accreditation standards are critical to ensure the safety and quality of our public healthcare system, but overlapping standards are placing an unnecessary burden on many health services. Public healthcare agencies must be accredited to receive funding and to continue providing a service. Accreditation usually follows a three-year cycle but most health services also undertake annual self-assessment and a mid-cycle review. These reviews monitor how an organisation rates its own progress against 10 National Safety and Quality Health Service (NSQHS) standards so that surveyors can recommend remedial action. Multiple accreditation causes financial and administrative strain, particularly on small rural health services. Colac Area Health Service spent $360,000 or 1.25 per cent of its operating revenue on mandatory accreditation in 2013-14, according to Chief Executive Officer Geoff Isles. “There is no doubt we need a rigorous, disciplined process that can measure whether we are providing a safe service. However, I remain to be convinced that the 10 national standards are actually designed to do that. There is no research that says they improve safety or quality.” Mr Isles says some of the national standards are particularly complex for smaller services like Colac. “For example, the cost and effort that goes into meeting standard 2 far outweighs any
benefit that consumers may have in terms of influencing the board’s strategic priorities, or influencing our provision of a service so that it matches consumer expectation.
Eastern Health would like to see government integration of the various standards and further examination of how performance can be monitored for specific outcomes.
“It’s a really expensive process, especially for a small place like Colac. We have very little administrative capacity but it has to come from somewhere.”
Bairnsdale Regional Health Service CEO Therese Tierney says her accreditation burden was reduced when she moved from Orbost to a larger health service.
Eastern Health Chief Executive Alan Lilly is a surveyor with the Australian Council on HealthCare Standards. While he does not object to the national standards, he is concerned about multiple accreditation.
“At the smaller facility we had to keep this continuous momentum around improvement and documentation. While many people say we should be doing that all the time, it’s quite onerous at a small place.”
“Accreditation is an endorsement to the community that your services are safe and are meeting the required standards set by the regulatory bodies. Importantly, it’s also an endorsement to staff of the services they are providing. As a general rule, we think accreditation is a very good process.
In spite of the administrative burden, Orbost progressed from receiving only ‘moderate’ achievement ratings to 11 ’excellent’ ratings and one ‘outstanding’ rating in a single accreditation cycle.
“Our key concern is that there are multiple accreditations now and a lot of them are not accrediting new or different parts of the service. They are reviewing exactly the same material and are meeting with the same range of people.” In addition to the NSQHS standards, Eastern Health must comply with seven other standards to receive full accreditation for its service mix. Mr Lilly says this has a multiplier effect on the cost of service delivery. “The CEO, the board chair and managers get involved and clinicians are diverted from providing services. Every hour that a manager or clinician puts into a standard is an hour that service is not given.”
“We started to realise that we were doing some things well, so we used it as a motivator. There was a lot of pride among our staff but I was always disappointed that if our corporate and governance structures were rated as ‘outstanding’ why did we have to prove that again in a different format for another accreditation body?” Ms Tierney says. The VHA believes all accreditation should have clear quality and safety benefits to consumers and multiple accreditation should be avoided where it does not improve service provision. The VHA would like to see governments explore streamlining our accreditation system, perhaps resulting in a hierarchy of standards with a core set of compulsory standards for all organisations and a supplementary set for the accreditation of specific service types.
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Australian Centre For Healthcare Governance
2014 Governance Excellence Award
This inaugural award showcased outstanding contributions to strengthening the governance of publicly-funded health and community services. Victorian Minister for Health, David Davis, congratulated the winner, Whitehorse Community Health, at the ACHG conference on May 14.
Finalists (from left): Robyn Lindsay of Bendigo Healthcare Group, VHA Chairman Anthony Graham, Yvonne Wrigglesworth and Marilyn Forde of Whitehorse Community Health, Minister for Health David Davis, Andrew Hynson of Cobaw Community Health, Sue Zablud and CEO Sue Matthews of The Women's and Jane Leslie of West Gippsland Health Service.
Winner: Whitehorse Community Health Service Implementing the strategic plan through quarterly goals Objective: To embed quarterly organisational goals as a performance and accountability measure and ensure the planning cycle is realistic and transparent, with timely reporting. Description: Development of quarterly goals and targets for all levels in the organisation. This process was extended to board level to improve governance and direction for key strategic imperatives, and to monitor performance and accountability in progressing projects. Organisational goals are reported against quarterly targets at board level and reviewed using a traffic light system. This ensures the board is informed about performance and accountability against strategic goals, not only day-to-day activities.
Finalist: The Royal Women’s Hospital Comprehensive orientation program for new directors Objective: To provide a clear and comprehensive orientation program that fully complies with government guidelines, enabling new board directors to become effective as quickly as possible. Description: The program has a clear structure outlining the range and purpose of meetings with senior staff and providing information about the hospital, strategic directions, and the board and governance context. The program has the option to add customised elements, depending on the needs/interests of new directors and includes the appointment of an executive sponsor to ensure the director’s orientation is supported with the adequate resources. A board ‘buddy’ is appointed to sound out ideas and assist the director to understand the working processes of the board.
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Finalist: Bendigo Healthcare Group Making strategy a reality Objective: To deliver world class strategic planning, business planning and performance reporting to the board of directors. Description: The development of the strategic plan focused on the ability to evaluate the impacts of goals and objectives. Measures were developed to demonstrate the delivery of the strategy, which was supported by a new business planning and reporting framework. Annual organisational targets were set on 90-day cycles. A new software system was implemented to measure and report progress and ensure accountability and transparency to the board.
Finalist: Cobaw Community Health Board decision template Objective: To reduce the time spent at board meetings, improve transparency and traceability and reduce the workload for staff preparing material for decisions. Description: Before the template was introduced, staff often made presentations to the board which were well prepared operationally but did not anticipate questions from the board. Now, any issue is prepared in a standardised manner according to template headings. This ensures consistency in the process and makes the reasons for the board’s decisions clear and transparent.
Finalist: West Gippsland Healthcare Group Clinical governance: a reality in regional Australia Objective: To provide a robust approach to clinical governance for the multidisciplinary/multi-agency Board of Management Sub-committee and assure the board that clinical care is safe and effective. Description: Clinical governance was recognised as a weakness, with the board struggling to understand the volume, range and complexity of clinical services provided. A new board committee was established comprising board members, executives, multi-disciplinary clinicians, consumer and clinician representatives from two main referral hospitals and the Gippsland Medicare Local. The Clinical Governance Committee replaced the previous Standards Committee and grouped clinical areas into three streams, each being the focus of a regular meeting. The committee has access to external clinicians and three consumer representatives to ensure inclusion of their perspective.
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GAVAN WOINARSKI EXECUTIVE DIRECTOR MERCY HEALTH FOUNDATION
Mercy Health Foundation
Philanthropy and endowments provide a different way of managing donations to provide untold benefits to patients, healthcare services and health professionals. A passion to provide the best care for those in need is a hallmark of our health system. Each day countless people provide expert and compassionate care in facilities and programs ranging from the acute to the ordinary. The care is exemplary and delivered by people who want to do their best. The commitment to provide care is coupled with a desire to continually improve and advance techniques, procedures and programs for the betterment of everyone: patients, clients and residents, carers, staff, health professionals, researchers and clinicians.
How philanthropy can fund innovative health projects to a safer model. These grants are always well received and provide the practical support necessary to turn ideas into reality. In addition, grants generate success and confidence that can gain momentum and further enhance prospects. Grants are also available for professional training and development. Such investment in the workforce is another valued source of funding for the health sector, but there is always a shortage of funds. The funds from grant-makers, government departments, philanthropists and fundraising activities are finite and unpredictable. Anecdotal evidence suggests such funding is often short of what is required. People report that they completed a certain project, made the assessment but lacked the funds to implement the results, so they were frustrated that the work was done but the benefits would not be forthcoming. How can we change this situation? Is there a way to minimise the gap between what is needed and what is available? Can we add some certainty to external funding sources? How can we achieve some autonomy over our funding needs? Fundraising and philanthropy are well known sources of external funding. Most research organisations, hospitals and health providers have a fund-raising
Crowded schedules and constant demands create busy and crammed routines for healthcare professionals. Yet, during and within the normal cycle of our healthcare system, many innovative ideas bubble to the surface that warrant investigation and testing. In response, professional bodies, government departments and grantmakers support innovation and best practice and provide funds to support projects to improve care, or for the purchase of specialised equipment to improve a particular procedure, introduce efficiencies or upgrade
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The Victorian Healthcare Association Issue 1 [MAY 2014] vha.org.au
department or foundation that secures donations for particular projects or equipment. They go to some lengths to increase the number of donations and the amount received. A typical repetitive cycle is: donations received, donors thanked, donations spent. Reserves are not accumulated and a sense of urgency recurs because the organisation needs more donations to meet its expectations. But the needs of the organisation and the timetable of the donors do not always intersect.
“Reserves are not accumulated and a sense of urgency recurs because the organisation needs more donations to meet its expectations.� Endowment funds and investment in philanthropic programs are effective ways to achieve some financial stability from sizable donations. An endowment fund generates unencumbered funds and the investment returns are predictable and therefore provide certainty. The capital sum is permanently reserved so it will generate income well into the future.
Philanthropy is different to fundraising. Philanthropy relies on securing donations after a relationship has been established with prospective donors. Philanthropy invites people to donate to advance, change and pioneer; philanthropists are not inspired by the mundane. Philanthropy is attracted to iconic projects, innovative programs and ideas borne of leadership. Philanthropy can make an enormous difference to the confidence, status and reputation of an organisation. A single, seven-figure gift can have a profound and lasting effect. Imagine how much has been donated to your organisation in the past five years and place it in an imaginary endowment fund at 6 per cent income a year. The sum you would receive is unencumbered income for the program of your choice. If your department receives $200,000 a year in donations, in three years the capital would be about $625,000 (6 per cent return less 2 per cent CPI) generating $29,000 a year to support a priority project or need. If bequests and the occasional big donation were added, and these unpredictable donations do happen, this endowment fund would increase further and subsequent distributions would be greater. Therefore, rather than raise money and spend it, why not direct donations into an endowment fund? Over time such a fund could build an organisation’s capacity to be autonomous or to fund a unique project that could make an enormous difference to the advancement of healthcare.
“Over time such a fund could build an organisation’s capacity to fund a unique project that could make an enormous difference to the advancement of healthcare.”
A technician working at the Mercy Health Breastmilk Bank.
“Philanthropy can make an enormous difference to the confidence, status and reputation of an organisation. A single, seven-figure gift can have a profound and lasting effect.” The Mercy Health Breastmilk Bank at Mercy Hospital for Women is a major initiative made possible by philanthropy and supported by its own endowment fund. The Mercy Health Foundation raised money to help purchase specialised equipment for the breastmilk bank, then secured further donations which were placed in an endowment fund specifically to support the breastmilk bank. Similarly, the Mercy Health Foundation has a large sum in an endowment fund which supports the Sheila Handbury Chair of Maternal Fetal Medicine. Over the years, St Vincent’s Hospital and its foundation have accumulated an endowment fund to support research. The late Dr Andrew Dent also endowed a large sum to St Vincent’s that each year supports staff training and the purchase of specialist equipment here and in the Pacific region.
This single gift has had a multiplier effect and serves as a beacon for others to follow. The Austin Hospital was established in 1882 through the efforts of Elizabeth Austin. Her philanthropy has proved an enduring legacy. Recently Pamela Galli, widow of Lorenzo Galli, made two significant donations to the University of Melbourne to establish and endow the Lorenzo Galli Chair in Melanoma and Skin Cancers, and the Lorenzo and Pamela Galli Chair in Developmental Medicine. Her $10 million in gifts will be invested in the university’s endowment fund to support these chairs and provide benefits to future generations of doctors and patients. Importantly, projects that are supported by their own endowments are immune to the vagaries of politics and shifting priorities. Thus, these pioneering projects enjoy continuing stability that will bring immeasurable benefits to healthcare generally, and to research, teaching and academic leadership. Philanthropy can play an important and permanent role in the advancement of healthcare, with untold future benefits, if we shift our focus from today to tomorrow.
This article is written to help advance philanthropy in health and its views are those of the author alone.
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DR FIONA LANDER SECONDEE, JUSTICE CONNECT ADVOCACY-HEALTH ALLIANCES NETWORK
Advocacy Health Alliances
Many patients with complex social circumstances will be at risk of poor health, often from chronic disease, drug or alcohol abuse, or poor nutrition. The same social determinants of health place these disadvantaged people at a substantially higher risk of experiencing legal problems. It is well established that there is a substantial level of legal need in Australia. In the Legal Australia-Wide Survey conducted in 2012, about 50 per cent of respondents reported experiencing one or more legal problems in the previous 12 months, with 65 per cent of legal problems being concentrated among 9 per cent of survey respondents. In Australia, nearly 30 per cent of people will initially seek the advice of a doctor, or another trusted health professional or welfare adviser, in relation to a legal problem – but health advisers will not always be well placed to help. A novel solution to this problem is to combine the efforts of advocates, including lawyers, with those of health professionals. Advocacy-Health Alliances (AHAs), based on the United States’ Medical-Legal Partnership model, are increasingly recognised as an effective response to the link between poor health and unmet legal need. The Medical-Legal Partnership model was created when Dr Barry Zuckerman,
Health-legal partnerships help vulnerable populations a paediatrician in Boston, Massachusetts, hired a lawyer to bring a case against a landlord who had failed to maintain housing to a habitable standard. As a result of this case, the landlord was compelled to remove mould and pests which were causing intractable asthma among Dr Zuckerman’s young patients. MedicalLegal Partnerships have since been adopted in the US, with more than 500 health and legal institutions partnering to deliver legal services to about 54,000 patients. In Australia, the Advocacy-Health Alliance Network was created to support new and emerging Alliances. Some Australian AHAs predate the US model. For instance, Banyule Community Health has been colocated with West Heidelberg Community Legal Service for more than three decades, delivering integrated services to marginalised and vulnerable residents of Heidelberg West. More recently, innovative services have been established to target specific vulnerable groups. The First Step Legal Service in St Kilda provides integrated legal and addiction medicine services, helping clients respond to their criminal charges while undergoing drug or alcohol rehabilitation. In its initial evaluation, the First Step program has shown a substantial drop in the rates of recidivism among its clients. The Acting on the Warning Signs project is a novel partnership between Inner Melbourne Community Legal and the Royal Women’s Hospital. Through this program, medical professionals have been trained to recognise and refer women experiencing legal problems – in particular, family violence. AHAs offer an exciting opportunity for pro bono lawyers to help marginalised and vulnerable patients. It is hoped that as recognition of the benefits of this model grows, lawyers will develop strong relationships with the health care sector to help those who most require assistance.
Justice Connect formed in July 2013 when PILCH Victoria and PILCH NSW joined forces to connect more than 10,000 lawyers and barristers with not-for-profit organisations and individuals who would otherwise go without legal representation. In partnership with Seniors Rights Victoria, Justice Connect operates free Seniors Law clinics which are co-located within health services. The Seniors Law program offers confidential legal assistance to older Victorians who cannot afford a lawyer in relation to legal issues associated with ageing. In particular, the clinic aims to prevent and minimise the impact of elder abuse. “We aim to raise awareness of the legal issues that older people face by working closely with the health sector. If an older person discloses a legal issue to their health provider, we can facilitate a referral,” says Seniors Law Principal Lawyer and Manager, Lauren Adamson. “Often elder abuse is hidden and victims are socially isolated. Sometimes, the only people they have contact with are their doctor and other allied health professionals.” Ms Adamson says research indicates that people with multiple legal problems tend to also have several health problems, and vice versa. “By working together to address the underlying social determinants of health, clients achieve better health and legal outcomes.” Seniors Law services are provided on a pro bono basis, meaning eligible clients are not charged professional fees. All information shared with Seniors Law staff is confidential. More information: www.justiceconnect.org.au/ our-programs/seniors-law/get-help
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Advocacy Health Alliances
Based on the medical-legal partnership (MLP) movement in the United States, Australia’s Advocacy-Health Alliance (AHA) model helps low-income and vulnerable populations have their basic legal needs met within a clinical health setting. In Victoria, Loddon Campaspe Community Legal Centre (CLC) and Bendigo Community Health are conducting a three-year pilot of the model, focused on paediatric patients with a disability and families living in poverty. These clients often face multiple social challenges, including access to education, income security, discrimination, homelessness, family breakdown, involvement with child protection services and violence. The Bendigo pilot is aimed at breaking the cycle of disadvantage by directly addressing their unmet legal needs.1 Historically, Community Legal Centres (CLCs) have worked alongside the health and community sectors. In 2006, Loddon Campaspe CLC and commercial law firm Clayton Utz set up a pro bono outreach service for vulnerable older patients, which was partly modelled on the Cancer Patients’ Legal Service at the Peter McCallum Institute in Melbourne. Research by Loddon Campaspe CLC Coordinator Peter Noble supports a targeted effort to build the model in Australia. His recommendations include that:
Bendigo pilot aims to break the cycle of disadvantage •
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•
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advocacy be undertaken for the establishment of pilot sites that consciously and critically apply the MLP approach in the Australian context consideration be given to establishing a national centre to support the evolution of MLP in Australia critical specialist/academic partners be identified for guiding the development of appropriate monitoring and evaluation processes for MLP in Australia a comprehensive survey be conducted across Australian legal, health and social services to identify the nature and extent of existing multidisciplinary practice akin to advocacyhealth alliances.2
Noble’s research highlights awareness within the community legal sector of the benefits of multi-disciplinary practice. More than 85 percent of respondents to his 2011 survey had received referrals from health service providers, and 40 per cent of them had referred clients to health services.3 A follow-up survey is being conducted this year by the Advocacy-Health Alliance Network to track the progress, nature and form of these relationships. The network is also fostering new and closer collaborations between health and legal services. West Heidelberg CLC and Banyule Community Health share Australia’s oldest health/law collaboration, which has been the focus of extensive research by Associate Professor Mary Anne Noone of La Trobe
University.4 She identifies five key criteria for integrated health/legal service delivery: 1. meeting a common purpose 2. increasing community access to services and support 3. assisting with identifying complex and inter-connected needs and developing responses 4. sharing common values and understandings 5. engaging the community in problem solving and solutions. More recent AHAs include Inner Melbourne Community Legal, which has received a $421,600 grant from the Legal Services Board to extend its Acting on the Warning Signs program with the Royal Women’s Hospital. This program has successfully combined professional education, early intervention and outreach legal services to achieve whole-of-hospital support. The Kirby Centre at Monash University has also received a $290,000 Legal Services Board grant to establish and evaluate health-legal partnerships at the Alfred, Cabrini and Latrobe Regional hospitals over the next two years. A postgraduate teaching program will also be delivered at each hospital to familiarise clinicians with legal concepts – further advancing the health-legal partnership model in Victoria.5 References 1. Loddon Campaspe CLC Advocacy-Health Alliance breaks new ground (April 2013). Available at: http://lcclc.org.au/2013/04/advocacy-health-alliance 2. Noble, Peter Advocacy-Health Alliances: Better health through medical-legal partnership (August 2012) final report of the Clayton Utz Foundation Fellowship. Available at: http://advocacyhealthalliances.files. wordpress.com/2012/08/aha-report_general1.pdf 3. Noble, Peter Advocacy-Health Alliances: Better health through medical-legal partnership (August 2012) final report of the Clayton Utz Foundation Fellowship, Page 18. Available at: http://advocacyhealthalliances. files.wordpress.com/2012/08/aha-report_general1.pdf 4. Noone, Mary Anne Integrated Legal Services: Lessons from West Heidelberg CLS (2012) 37 (1) Alternative Law Journal 26. Available at: http://ssrn.com/abstract=2030556 published in the Alternative Law Journal (Vol 37, No 1, 2012). 5. Legal Services Board 2013 Major Grants Awarded may be accessed at http://www.lsb.vic.gov.au/grants/major-grants/
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NINA BOWES VHA AGED CARE PROJECT OFFICER
Aged Care Readiness Project
The number of Australians aged 85 and over is projected to increase from 0.4 million in 2010 to 1.8 million by 2050. More than 3.5 million older Australians are expected to access aged care services each year and about 80 per cent of those services will be delivered in the community. These well-known statistics were a key driver for the comprehensive recommendations of the Productivity Commission’s Caring for Older Australians report released on the 8th of August 2011 and for the Living Longer Living Better aged care reform package introduced into federal legislation on the 28th of June 2013. The ageing population is sometimes described as a challenge that needs to be met, a crisis on the horizon or an ‘ageing tsunami’. Assistant Minister for Social Services Mitch Fifield along with many consumer advocates reject such phrases and highlight the wealth of wisdom, opportunity, potential and experience that older people contribute to Australian society. The reality is probably somewhere in between. Yes, longer life is something western society has been striving for and should celebrate. Yes, the wisdom and experience that come with age are to be valued and utilised. Yes, older people have
Aged care reforms: an opportunity in change spent their lives contributing to our society and economy, and are entitled to receive the care they need. And yes, the trebling of our over-85 population in the next 35 years will present enormous challenges. The Living Longer Living Better reform package is not a panacea for all the challenges of a rapidly ageing population with an escalating acuity level, who also expect more choice, control and quality in services. It is however, a big step in the right direction. These reforms are designed to improve transparency, accessibility, affordability and choice for consumers, to ensure that those who can contribute do, and to enable the sector to remain sustainable in a future with dramatically increasing demand. The public sector is well positioned to succeed in the reformed aged care environment. Public sector services already provide high quality clinical care and have good reputations within their communities. They are also well equipped to respond to what their consumers want, to partner with them in decision making and to start providing consumer directed care. The key reform package implementation date of 1 July 2014 is fast approaching and all providers should be ensuring that they are thoroughly prepared. For those who are feeling panicked: The grand-parenting arrangements for current aged care consumers mean that the immediate impact of the reforms on 1 July 2014 may not be too drastic. For those whose calm is bordering on inaction: It is important to recognise that significant sector-wide changes are being implemented and they require considerable thought, planning and action. For all public sector providers: These reforms offer major opportunities for those that are ready to take advantage of them.
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VHA AGED CARE PROJECT The VHA is running an Aged Care Readiness Project to assist our public residential aged care provider members to move successfully through the reform process. A well-prepared aged care provider has: •
an aged care vision, strategy and action plan in place that incorporates the reforms and changing sector environment
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an engaged board, senior executive and staff team who understand the reforms and how they will affect their own roles within the organisation
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an embedded and shared commitment to continuous improvement and best practice
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a workforce and cultural change-management strategy, including training and other staff engagement activities
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a detailed consumer and community engagement strategy
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a plan to successfully compete in a market-driven environment
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a comprehensive understanding of the revenue and cost structures of aged care within the whole organisation
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an understanding of future infrastructure requirements in a changing sector environment
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up-to-date systems ready for the changes to service structures, provision and billing after 1 July 2014
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a shared culture of accountability and responsibility for quality and risk management between the board, senior executive, facility staff and consumers.
For further information about the Aged Care Readiness Project or to receive regular newsletters please email agedcare@vha.org.au
RESPONDING TO AGED CARE REFORM •
Have a vision for your aged care services and align this with clear, board-directed action.
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The Victorian Healthcare Association Issue 1 [MAY 2014] vha.org.au
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GAYE BRITT SENIOR POLICY ADVISOR VICTORIAN HEALTHCARE ASSOCIATION
Elective Surgery Access
Elective surgery waiting lists are under increasing scrutiny at the same time as demand is rising, more complex procedures are being performed in the public system and consumer expectations are growing. Reports of longer waiting lists and times, the existence of ‘secret’ waiting lists, and the failure of Victorian hospitals to meet national targets are fuelling concerns that the state’s public hospital system is unable to keep up with demand. But do these reports tell the full story, or are other factors affecting access to elective surgery? This article discusses four common myths and the degree to which they are useful or accurate. MYTH 1: “The size of the waiting list and median waiting times are the most appropriate measures for monitoring access to elective surgery.” This is untrue. The most important measure of access is whether the patient is seen in a clinically appropriate time. This varies according to factors such as the likelihood the condition will deteriorate or cause serious harm, the impact it is having on the patient’s life, and the degree of pain or loss of function they are experiencing. The length (including changes in the length) of the waiting list does not reflect this. Similarly, changes in median waiting time, even for conditions classified for a procedure, do not necessarily reflect changes in access to elective surgery.
Elective surgery waiting lists: busting the myths Clinical, social and other factors relevant to the patient experience will differ between patients requiring the same procedure. Further, access is only one measure of elective surgery performance. Cost effectiveness is another. A very small waiting list is counterproductive because it becomes difficult to fill a surgical list and, consequently, the cost of the surgery increases. Waiting list size is a KPI for Victorian hospitals that report to the Elective Surgery Information System (ESIS). This is stated in their Statement of Priorities (SOP). The VHA advocates that waiting list size should be eliminated from health service SOPs, and that access measures should be based on patients being seen within clinically appropriate times. MYTH 2: “The way access to elective surgery is measured and reported gives us a clear picture of the status of our public health system.” This is partly true but the way access is measured and reported can be misleading. There are several reasons for this. 1. The waiting list does not include all elective surgery procedures performed by all Victorian public hospitals. At present, 35 hospitals report to ESIS and only their ‘reportable procedures’ are subject to mandatory reporting. Non-reportable procedures are not represented on the waiting list and smaller, rural health services that perform elective surgery procedures do not report to ESIS. The Australian Institute of Health and Welfare (AIHW) and the Royal Australasian College of Surgeons have developed a proposal for health ministers that recommends expanding the scope of reportable procedures and standardising the categorisation of patients on the waiting list.1 2. Waiting lists represent only part of the process. The time a patient waits to see a specialist who will put them on the list is not reported.
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A review of elective surgery waiting list management was reported to the Victorian Minister for Health in August 2012. This included recommendations for expanding waiting lists to include initial consultation and referral, through to specialist outpatient or elective surgical care. An access policy concerning specialist clinics in public hospitals has since been developed. Health services are expected to comply with this policy by 1 July 2015. While the policy says access to specialist clinics should be reported differently and separately to waiting lists, there is potential for reporting to be aligned. 3. Hospitals are inconsistent in the way they categorise patients on the waiting list and the way they use the ‘not ready for care’ category. This makes it difficult to accurately compare reporting among hospitals, and particularly among states and territories. A paper by the AIHW and the Royal Australasian College of Surgeons2 identified inconsistent definitions of urgent elective surgery across jurisdictions. They reported various recording practices for staged patients’ waiting times in some public hospitals. They also found significant variation for high-volume procedures that would usually have a fairly uniform patient mix (known as ‘indicator procedures’). For example, the proportion of patients admitted for total hip replacement in urgency category 2 was 25 per cent in New South Wales and 74 per cent in Victoria. The proportion of patients admitted for myringoplasty in urgency category 3 was 86 per cent in NSW and 29 per cent in Queensland. The VHA advocates that more hospitals should report a broader range of elective surgery procedures to ESIS, and reported waiting times should include the wait for an initial specialist consultation. The VHA also supports mechanisms to improve consistency in categorising patients on the waiting list. The VHA view is mostly consistent with the AIHW/Royal Australasian College of Surgeons proposal to health ministers and, in some cases, goes beyond their recommendations.
MYTH 3: “Access to elective surgery can be improved through productivity improvements by our health services.” This is only partly true. Potential productivity improvements may be more achievable across the health system, rather than within individual health services. Measures to improve productivity have been implemented to various extents. This includes significant capital investment in large hospitals such as The Alfred and The Austin, to provide dedicated elective surgery centres which quarantine elective surgery from emergency surgery demands. However, many hospitals have redesigned and reorganised to significantly improve throughput and reduce postponement rates. Capacity and productivity can also be increased through workforce changes. A recent program to introduce advanced practice nurses in endoscopy sites across Australia, including four Victorian health services, has reduced waiting times, including one extreme case where the waiting time for routine endoscopy decreased from seven years to 40 days3. Most health services have established mechanisms for managing demand and improving elective surgery referrals. Often the presenting problem can be treated or managed by the physiotherapist, negating the urgency or demand for surgery. One hospital reported that 40 per cent of new patients at its physiotherapist-led shoulder clinic were discharged from the orthopaedic service without surgery. Patients were satisfied with the outcome and surgeons felt that the appropriateness of referrals had improved. Most felt the overall experience of working in the outpatient service had improved since the clinic began.4 Another opportunity is to reduce variation in clinical practice (ie whether a patient has a particular surgical procedure and how it is performed). Enabling surgeons and hospitals to compare their own practice to peers’ can increase consistency and encourage best practice. Finally, broader health system change may produce the greatest improvements in productivity. This includes mechanisms, such as a pooled waiting list, for better matching demand with capacity. An evaluation of six years of data for joint replacement in Ontario showed a single waiting list (as opposed to each region having its own) had the same effect as reducing demand by 5 per cent each year.5
But a single list has practical limitations, such as the potential for ‘double up’ in specialist consultations before and after surgery. Several Victorian health services advocate inter-hospital referral whereby a hospital operating at capacity could refer a patient other hospitals with spare capacity before their initial specialist consultation, overcoming any issues with clinical accountability and post-surgical follow-up. Strict policies and procedures would be needed to govern how this might work. Automatic referrals may also enable surgeries to be performed where it is safest and most cost effective. A specialised hospital would accept patients for specific procedures based on certain criteria, and return the patient to the referring hospital post-op for the remainder of their acute stay. For this to work effectively, two-way agreements with clear criteria for referral and acceptance must exist - and bed availability cannot be one of the criteria. MYTH 4: “The only way to improve access to elective surgery is to invest in more capacity in the health system.” This is only partly true and does not consider the potential productivity improvements mentioned above. Opportunities exist for using latent infrastructure, instead of funding new facilities. These could include contracting capacity from the private sector, using operating theatres out of hours, and underutilised facilities in smaller rural health services. Victoria now contracts capacity from the private sector through the Competitive Elective Surgery Initiative. Under this initiative, a private hospital may bid to perform certain elective procedures on behalf of an ESIS-reporting public hospital. Some public hospitals have reported a more complex patient mix as a result of this initiative. This is because less complex patients are treated in the private hospitals, while public hospital funding still assumes a mix of complex and less complex patients – as was the case before. As a result, public hospitals are being inadequately funded for these procedures. This also increases the challenges associated with workforce, demand and capacity planning, particularly in smaller hospitals.
The biggest improvements would be achieved if ESIS-reporting public hospitals operated outside normal surgery hours, but funding does not adequately cover the cost of theatre staff after hours. Underutilised infrastructure at rural and regional health services and on the urban fringe could also be better used. But any additional surgery would need to remain within the scope of practice of these hospitals – and to ensure transparency they should report to ESIS. A study by the Organisation for Economic Co-operation and Development on tackling excessive waiting times for elective surgery noted several ways to increase supply, each involving different costs and time scales. It concluded that purchasing from the private sector may be the most appropriate strategy in the short term but, in the long term, it may be cheaper to expand activity by increasing capacity within the public sector6. References 1. Australian Institute of Health and Welfare & Royal Australasian College of Surgeons, “National definitions for elective surgery urgency categories – Draft proposal for Health Ministers”, 24 September 2012 2. Australian Institute of Health and Welfare & Royal Australasian College of Surgeons, “National definitions for elective surgery urgency categories – Submission information paper”, March 2012 3. Source: Health Workforce Australia, “Expanded Scope of Practice and Aged Care Workforce Reform Progress Report”, 2014 4. Source: Entrant to VHA Annual Award 2013 5. Source: Cipriano et al, “An evaluation of strategies to reduce waiting times for total joint replacement in Ontario”, Medical Care, Vol 46, No 11. 11 November 2008 6. Source: Hurst J and Siciliani L, “Tackling excessive waiting times for elective surgery: A comparison of policies in twelve OECD countries”, OECD Health Working Papers, OECD, 2003. p45
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CHRIS TEMPLIN POLICY ADVISOR VICTORIAN HEALTHCARE ASSOCIATION
Disaster Response & Recovery
On 7 February 2009 Victoria experienced the most severe bushfires in its history. On the day now known as Black Saturday, CFA crews attended more than 300 fires, 15 of which were catastrophic in their size, ferocity and impact on people and communities. Communities in the Nillumbik, Mitchell, Murrindindi, Yarra Ranges and Whittlesea local government areas were significantly affected. High fuel loads, extreme heatwave conditions, low humidity and a storm-force wind combined to form a swift fire front that travelled from Kilmore East to the Healesville area, before a cool change and accompanying switch in wind direction drove the blaze north-west and across the township of Kinglake. The damage from this fire alone was unprecedented in Australia’s history. In the time it took authorities to control the blaze, 159 people died, 305 were injured, 1780 houses were destroyed and an area of 168,542 hectares was burnt. The residents of the affected towns faced the daunting task of rebuilding their lives, homes and communities. Homes, shops, agricultural infrastructure and fences needed rebuilding, and the physical and mental health of residents needed support and co-ordinated rehabilitation.
Community health services con recovery role five years after B Among the myriad government, nongovernment and faith-based organisations dedicated to assisting the recovery, VHA members were at the forefront. Nexus Primary Health (then Mitchell Community Health Service) operated in much of the area affected by the Kilmore East fire, which was the most significant. Nexus and Nillumbik Health proved vital in the immediate and long-term recovery of the community. Under trying conditions, their staff worked tirelessly to co-ordinate the psychosocial response in the Mitchell and Murrindindi Shires. This involved preliminary work determining who needed care, and then triaging and providing referrals. Nexus eventually took responsibility for case management, local area coordination, a web-based service directory, the statewide bushfire helpline and trauma counselling, in addition to maintaining its usual programs and services. Nillumbik Health had a seven-day presence at each relief centre, coordinating relief needs, advocating to government on local community needs and managing the accreditation of volunteers. “We were also working with local government to provide immediate psychological first aid to those not willing to leave their properties,” says CEO Amanda Murphy. “We were also providing them with GPO services and vaccinations for tetanus and pertussis,” Both health services took a holistic approach, ensuring that people had support across a range of services instead of dealing with single elements or illnesses. Nillumbik Health and Nexus have maintained a role in the long-term recovery effort and, contrary to other approaches, have focused on integration with the mainstream health system. They have taken the lead from their communities and remained available to provide care when and where it is required.
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“If people seek, help we provide,” Ms Murphy says. “For most people, a new sense of ‘normal’ has developed. We remain engaged with the recovery communities and with local government.” The lessons of Black Saturday were hard learnt. The Victorian Bushfires Royal Commission has recommended sweeping changes to how each bushfire season is approached. For Nexus, many of these lessons applied when fires again hit the Mitchell region again in February this year. This time, Nexus and Mitchell Shire Council were prepared and followed agreed protocols on delivering services to affected areas. Nexus deployed staff to relief centres when asked by the shire, and worked collaboratively with other providers.
ntinue their Black Saturday While the impact of the fires was much less severe than on Black Saturday, the community and local service providers’ response was more co-ordinated and clear. With time the physical damage to property is repaired, the bush regenerates and communities rebuild their lives, but the long-term psychosocial impact of the 2009 fires continues to ripple through Victoria. Nexus emphasises care that fosters hope, resilience, a belief in recovery and personal growth, while acknowledging the impact of grief, loss and trauma. The VHA’s members provide healthcare in every local government area in Victoria and, as the inevitability of future bushfires and natural disasters is clear, so too is the fact that these services will be at the forefront of providing on-the-ground care and support to those affected.
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Nexus provides the Home and Community Care service in Mitchell Shire, so staff contacted clients when the fire broke out to ensure that people had plans and were safe. On Saturday afternoon, Mitchell Shire requested the use of our buses to transport people. “Phone calls for psychological assistance began early in Saturday evening, and we were asked to send staff through active fire zones to talk to distressed people. One request I distinctly remember was to talk with family members who had left their property in a couple of cars, but only one car had made it to safety. “We recommended involving local church ministers but it was pretty clear that health and community providers in affected areas were already overwhelmed by the magnitude of it all. People working to support others were also acutely aware of the threat to their own property and families. “On Sunday, Nexus convened a senior management meeting and we contacted staff and checked on clients. We held a meeting of all staff on Monday to talk about service continuity, additional services and support requirements, and to provide a safe
grounded environment, and dispel any rumours. “We quickly learnt that misinformation circulates faster than accurate information and the term ‘verify, verify, verify’ became our catchcry in the fireaffected areas. “We operated in local teams in areas where we had in the past, and still continue to, provide services. We said ‘no’ to things we didn’t think we could do. “We ended up doing case management, local area co-ordination, establishing a web-based service directory, operating the statewide helpline, and providing trauma counselling, but we kept our other services going too. “We tried to link people to mainstream services where it was clear that pre-existing health issues were inhibiting their recovery. We did case management in pairs and had staff return to base at the end of the day. It seemed to help us retain good staff and remain focused on recovery.” – Nexus Primary Care CEO Suzanne Miller describing the community health service response to Black Saturday.
Regeneration following the Mitchell Shire fires.
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