The National Health Reform Agreement - Essay Example

? Introduction The National Health Reform Agreement - National Partnership Agreement on Improving Public Hospital Services is an agreement signed between the Commonwealth of Australia and its states and territories (The National Health Reform Agreement, 2011). From an economy viewpoint, this is an agreement based on “federal financial relations” but from a social and humanitarian point of view, this agreement is aimed at patient safety, equality and quality of care (The National Health Reform Agreement, 2011, p. 1). The objective of this agreement is to help the patients have lesser waiting time for undergoing elective surgery, and in emergency department (ED) and also have access to better subacute care services (The National Health Reform Agreement, 2011, p. 2). The agreement has a basic ethos of “social inclusion” and has committed both the Commonwealth and the States to spend a reasonable amount of money towards developing better infrastructure, facilities and care in public hospitals (The National Health Reform Agreement, 2011, p. 3). Furthermore, socially disadvantaged people like indigenous groups have been incorporated as special beneficiaries of this agreement (The National Health Reform Agreement, 2011, p. 3). The investigations and reveiws that have been conducted on the effectiveness and implementation of the agreement have shown that some positive changes have been initiated. Keeping this in mind, and inquiring about the positive and negative aspects of the agreement, this paper envisages finding out whether this agreement is sufficient to achieve a patient-centered and all-inclusive scenario in the Australian health care system. It is hypothesised that though the target-oriented, porcess-centered and organisation-centered approach in the agreement has resulted in many positive outcomes, the health care system of Australia still lacks in sharing of leadership, two-way communication and a whole-of-hospital approach. Background The “overcrowding” in public hospital Emergency Departments and “access block to poorer patients” has been identified by this agreement as major issues affecting not only the quality and commitment to health care but also patient safety (Baggoley, 2012). The prevailing situation has been alarming in the sense that “ED overcrowding and access block” was causing about “20-30% excess mortality rate” among the patients (Baggoley,2012; Richardson, 2012, p.126). Another difficulty that arose from this situation was the “prolonged inpatient length of stay” (Baggoley, 2012). Highlights The highlights of the agreement are as follows. The agreement has set forth a national target for elective surgery to ensure that all the “Urgency Category patients” who are waiting for their turn for surgery, get the same done within the “clinically recommended time” (The National Health Reform Agreement, 2011, p. 14). For materialising this commitment, the agreement has the Commonwealth give an amount of $ 650 million (The National Health Reform Agreement, 2011, p. 14). The programme initiated for this, named National Elective Surgey Target (NEST), has its focus on giving within necessary time surgery access to all patients, and cutting short the “average waiting time” for patients whose surgeries are already lagging behind time (Western Australia Department of Health, n.d.). Once these targets are met with, the agreement has also a provision for “reward funding” of up to $ 200 million (The National Health Reform Agreement, 2011, pp. 16-17). There is also an elective surgery capital funding instituted by this agreement (The National Health Reform Agreement, 2011, p.27). Elective surgery is defined as “surgery that can be delayed for at least 24 hours” (The State of our Public Hospitals June 2010 Report, 2010). The procedure for deciding upon elective surgery is that the patients who approach public hospitals are enlisted in a waiting list by the doctors on the basis of the clinical judgment they make in view of the medical urgency of the matter (The State of our Public Hospitals June 2010 Report, 2010). By the agreement, the government of Australia is bound to give $ 150 million within a time span of four years to enhance the “elective surgery capacity in public hospitals” in order to meet the target put forth by NEST (The National Health Reform Agreement, 2011, p. 27). The States and Territories are bound by this agreement to work with “Local Hospital Networks” and to enhance their elective surgery capacity and performance (The National Health Reform Agreement, 2011, p. 14). This provision was made in view of the prevailing problems in patient categorization while deciding upon elective surgeries (The Expert Panel Review, 2011, p. 23). The categorization was often fraught with anomalies with respect to surgical specialties and also in connection with the choice between hospitals (The Expert Panel Review, 2011, p. 23). The socially and economically backward patients and also the patients who lived far away from the hospitals were found to not getting equal prioritisation as others get (The Expert Panel Review, 2011, p. 23). It was to rectify these anomalies that NEST was formulated. National Emergency Access Target (NEAT) is the next major highlight of the agreement by which 90% of all the patients approaching the emergency department of a public hospital will “either physically leave the ED for admission to hospital, be referred to another hospital for treatment, or be discharged within four hours” (The National Health Reform Agreement, 2011, p. 30). But it has also been noted that this provision will not be implemented against the discretion of the medical practitioners involved (The National Health Reform Agreement, 2011, p. 30). This measure was first of all made necessary by the more than 50% rise in “ED presentations” within a very little time span of 10 years, between 1999 and 2009 (Lowthian et al., 2012). As Khanna, Boyle, Good and Lind (2012b) had revealed, early discharge was instrumental in controlling overcrowding and improving the smoothness of patient flow (pp. 510-517). For the facilitation of NEAT and as reward funding, the National Partnership is bound to provide an amount of $500 million between the periods 2010-11 and 2015-16 (The National Health Reform Agreement, 2011, p. 30). Yet another provision of the agreement is with respect to improve the “ED capacity in public hospitals” so that NEAT target can be materialized (The National Health Reform Agreement, 2011, p. 39). The set aside amount by the Partnership under this head has been $ 250 million (The National Health Reform Agreement, 2011, p. 39). This money has been envisaged to go into ED capacity building as well as “patient management” (The National Health Reform Agreement, 2011, p. 39). The National Partnership Agreement on Improving Public Hospitals Services is also committed to give $ 1.623 billion to the States and Territories for increasing the number of subacute care beds available “nationally, in hospital and community settings” (The National Health Reform Agreement, 2011, p. 43). To determine how many more subacute beds needed to be added and in which facilities, was one topic of interest for the agreement to be resolved in a time bound manner (The National Health Reform Agreement, 2011, p. 44). Last but not least, the agreement has also established a “$ 200 million flexible funding pool” that States and Territories can avail to better the performance of emergency departments, to avoid the time lag in elective surgery, and to have first class subacute care services (The National Health Reform Agreement, 2011, p. 50). The States and Territories are given necessary autonomy to direct these funds towards prioritised areas within the mandate of the agreement (The National Health Reform Agreement, 2011, p. 50). Reviews and Research on the Implementation of Agreement Patient Safety and Risk Management Culture There have been arguments pro and against the National Partnership Agreement on Improving Public Hospital Services. Patient safety and access have been the prime goals of the agreement (Richardson, 2012, p. 126). The first indications of positive changes have been picked up by Geelhoed and de Klerk (2012) when they found out that in three big hospitals in Australia, through implementing the agreement, overcrowding was reduced, and there was a 13% decrease in mortality rates (pp. 122-126). The remedy put forth by this agreement to overcrowding and reduced bed contention being “capacity management and early discharge”, the question was raised whether these measures alone were sufficient (Khanna, Boyle, Good, and Lind, 2012a, p. 92). Investigating data from 23 public hospitals in Queensland, Khanna, Boyle, Good and Lind (2012a) showed that early discharge was a step that could give a positive escalation to “occupancy levels in the inpatient departments,” minimize access block, and avoid unnecessary Length of Stay of patients in the Eds (p. 97). This was a positive feedback on the agreement. On the contrary, Lowthian et al. (2012) observed that the 4-hour ED discharge target set forth by National Partnership Agreement might not be practical unless the whole system is revamped to lead up to effective time reduction in ED discharge (p. 132). Improvements in Organisational Systems and Processes The effectiveness of the agreement has also to be assessed in terms of improved organisational systems and processes. How the approach of putting up targets, is responded to by the system and the processes has to be examined. The disadvantages of setting targets have been listed by Baggoley (2012) as 1) over-emphasis on meeting the target at the risk of compromising quality of treatment, 2) limiting damagingly the discretion of clinicians and patients owing to “lack of consultation, planning and communication”, and 3) tendency of malpractices under the guise of target norms. Notwithstanding this criticism, Kelman and Friedman (2009) found out that the NEAT 4-hour target once implemented, decreased death rates among ED patients, and reduced access block (pp. 917-46). The Expert Panel Review of Elective and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services: Supplementary Annexure Report to COAG (2011) also inferred that once the NEAT and NEST targets were set, the number of ED admissions that were discharged on the same day was increased by 43% (The Expert Panel Review, 2011, pp. 20-21). Other changes visible were 1) discharges being on the high during the last 20 minutes of the prescribed 4 hours, 2) no negative influence of target-setting on quality of care or availability of resources, 3) no impact of target on return visits or mortality and 4) better awareness among hospital administrations on the issues created by emergency department overcrowding (The Expert Panel Review, 2011, pp. 20-21). The Expert Panel Review (2011) also concluded that elective surgery targets put forth by the National Partnership Agreement on Improving Public Hospital Services had the effects of less waiting period for surgery and less waiting period for getting referred for surgery (The Expert Panel Review, 2011, pp. 24-25). There have also been negative outcomes of the agreement spotted at organisational and process levels. The major ones were, gaming, and an increase in admissions (The Expert Panel Review, 2011, pp. 24-25). In order to overcome these negative aspects of the agreement, remedies suggested are, commitment across the whole system, coordinated work between administrators and clinicians, engagement and leadership by medical practitioners, a whole-of-hospital approach, clinical redesign in view of patient safety and improved quality of care, clear definitions, across the players, scope for flexibility in comparisons of jurisdictions in view of specific positions, regular monitoring, proper dynamics between targets and demands, and effective training of professionals involved (The Expert Panel Review, 2011, pp. 13-15). Appropriate Quality Tools , Techniques and Strategies to Improve Quality and Safety The agreement, as a whole, has shown that it is possible to adopt tools, techniques and strategies to improve quality and safety in health care systems. The federal nature of the agreement is one advantage that makes the commitments in the agreement mutually binding. The sharing of financial burden assures that there is a second party monitoring at all stages. The reward fund system is yet another motivating factor for performance. The autonomy imparted to the States and Territories in utilizing the “flexible funding pool” and the binding nature of the capital funds combine to form a fine balance of control and autonomy. The setting of a time frame for implementation of the provisions and within the implementation process (eg.: the 4-hour ED discharge target) is another measure to avoid implementation lags. Areas for Further Action Though the agreement has shown some positive changes as its result, the mixed feedbacks discussed above also point to the need for further research on the outcomes. It has to be confirmed, to what extent the positive changes manifest can be accounted by real improvements and to what extent by “alterations in recording practice” (Richardson, 2012, p. 127). Though the agreement has made effective alterations to organisational and process-level scenarios, the professional, and personal aspects of the system have been overlooked so far. For example, the leadership role to be shared across the groups involved in medical profession, the need for professional communication and coordination among the medical and organisational professionals involved, the communication processes among the patients, their families and the medical practitioners and interpersonal skills involved. Leadership, Professional Communication and Interpersonal Skills The agreement to be a full success, Baggoley (2012) has called for “open, honest two-way communication between executive and staff with a shared goal and the right motivation (and) a willingness to totally change current processes.” As the expert review panel had suggested, there has to be explorations beyond targets realising that targets can be the starting point for achieving further and overall changes (Expert Panel Review, 2011, p. 1). It is clear from the above discussion that patient safety depends not only on setting procedural targets but also on the clinician’s engagement, adoption of best practices and also improved communication between the players involved in health care including staff and executives. A whole-of-hospital approach demands much more than financial commitments, capacity building, and strict deadlines though they can be a starting point (Hillman, Braithwaite and Chen, 2010, 79). It is observed that the health reform will be effective only when the clinicians have a role in “service planning and resource allocation decisions” (Public Hospital Report Card 2011, 2011, p. 3). Along with that the organizational leaders have to learn to design and formulate “processes, functions, or services”, focusing on patient safety, which again amounts to a new work management culture (Patient safety essentials for healthcare, 2009, p. 87). Even when a four-hour target is fixed for ED discharge, several “choke points” have been found to exist in the system depending upon size of the hospital, mindset and training of the clinicians involved, level of occupancy, and the stress caused by all these on the system (Khanna, Boyle, Good, and Lind, 2012b, p. 517). This first review report has recommended promotion of “clinical engagement, best practice and shared learning within and between jurisdictions” for better results from the agreement (Expert Panel Review, 2011, p. 94). The second important recommendation pertained to the establishment of “surgical taskforces” in “all jurisdictions” and to connecting them for networking of crucial and useful information on care and management fronts (Expert Panel Review, 2011, p. 94). The third major recommendation is for hospitals and Local Hospitals Networks to collect relevant data to assess the success of the implementation of the agreement (Expert Panel Review, 2011, p. 94). All the other recommendations pertain to imparting clarity to the implementation process and setting time spans and deadlines (Expert Panel Review, 2011, pp. 95-97). Legal and Regulatory Requirements: Implementation and Monitoring Australia has a history of its health reforms being scuttled by State governments as they lack interest in investing funds and taking up responsibility (Public Hospital Report Card 2011, 2011, p. 2). The new health care agreements were introduced to overcome this problem through federal commitments and monitoring (Public Hospital Report Card 2011, 2011, p. 2). Though the Commonwealth has under these agreements committed itself to pay for “50 percent growth in hospital services by 2017-18”, how much of this money will be provided to public hospitals is yet to be seen (Public Hospital Report Card 2011, 2011, p. 2). This is crucial just because the public hospitals now gravely lack “the capacity to meet the demands of an ageing population” and other categories of patients as well (Public Hospital Report Card 2011, 2011, p. 2). There is also the alarming situation that despite the health care agreements, the public hospital beds available per capita are constantly declining (Public Hospital Report Card 2011, 2011, p. 2). The meaning of this situation for the patients is that they will have to wait longer in EDs and for elective surgery (Public Hospital Report Card 2011, 2011, p. 2). Recent news reports have revealed that the elective surgery waiting lists are blowing out of proportions just as 46,000 people are presently awaiting surgery (Bell, 2012). The “median waiting period” for patients having any disease, has to be still brought down from the prevailing “35 days” (Australian Institute of Health and Welfare, 2012, p. 423). These prevailing issues point to the need for a foolproof monitoring mechanism for the implementation of the agreement. Conclusion The National Partnership Agreement has introduced a risk management culture into the healthcare system that is highly responsive to patient safety as is defined by Youngberg (2010, p. 10). The need of the hour is to further integrate risk management, quality management and patient safety (Youngberg, 2010, p. 13). The sharing of information through Local Hospital Networks as suggested by the agreement is equally important in that it will help develop a “knowledge”-based system of health care in the country (Sharma, Wickramasinghe, and Gupta, 2005). More authentic data on National Partnership Agreement on Improving Public Hospital Services is expected to come out by the end of 2012 (COAG Reform Council, 2010-11, p. 101). Many hospitals have so far been benefited by the agreement and in the future, “activity-based funding” is expected to give the necessary motivation for hospitals to perform well (COAG, n.d.). In Australia, the life expectancy still remains dependent on the economic status of an individual and “if you are poor long term”, there will be a 3-year reduction in the average life expectancy (Willis, 2008, p. 3). This is a situation that leaves much to be desired further. The National Partnership Agreement has initiated change through the new process-level and organisational culture introduced, and the financial resources pooled in but there is a need for incorporating coordination based on leadership, communication and interpersonal integration. The future paradigm has to be based on a whole-of-hospital approach that is patient-centered. References Australian Institute of Health and Welfare. (2012). Australia’s health: 2012. Canberra: Australian Institute of Health and Welfare. Baggoley, C. (2012, July 27) The impact of targets on the quality of care (Powerpoint Presentation). Retrieved from http://imgpublic.mci- group.com/ie/ICEM2012/Wednesday/track7/Chris_Baggoley.pdf Bell, S. (2012, October 16). Elective surgery waiting lists blow out [Television broadcast]. ABC News. New York City, NY: American Broadcasting Company. Council of Australian Governments. (n.d.). Health and ageing. 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