A new report has just been published by the Sax Institute based on a piece of work that myself, Katie Moon and Karen Gardner. The NSW Department of Family and Community Services (FACS) commissioned this review to explore which approaches to outcomes-based commissioning have been effective in improving client outcomes in the human services sector. Stage One of this review found that very few studies actually explored the impact of commissioning on consumer outcomes. Stage 2 examined literature about when and how consumers have been involved in the various stages of the commissioning cycle, then searched for evidence within that literature about improvements to client outcomes.
Although many sources described the theoretical benefits of consumer engagement, little empirical data exists to demonstrate these outcomes in practice. Perceived benefits of consumer engagement fell into two categories: benefits for consumers participating in commissioning processes and improvements in services, including to environments (e.g. decor, food) and access. The review revealed no evidence of the effectiveness of outcomes-based commissioning in improving client outcomes. The most universal element of the reviewed literature was the description of the challenges of consumer engagement in commissioning and recommendations about how to undertake it effectively.
We conclude that, as both commissioning and consumer engagement are relatively new fields, there is an opportunity to grow the evidence base in coming years, especially if we can achieve consistency about how engagement and commissioning processes are described and measured.
You can download the full report you can find it here.
The Consumers Health Forum of Australia (CHF) is the national peak body representing the interests of Australian healthcare consumers. CHF works to achieve safe, quality, timely healthcare for all Australians, supported by accessible health information and systems. One of the things they do in meeting these aims is produce a journal called ‘Health Voices‘ which is published two times a year to promote debate on health care issues affecting all Australians and of interest to health consumers, government and industry.
The latest issue focuses on how consumers can influence research. I have the privilege to have a piece in this issue alongside a number of leading research and consumer engagement voices, which I have written about a the co-produced project on the NDIS which I have previously written about in this blog. In this I reflect on what we learned about doing consumer-engaging research and where next for this field. The full article is open access and can be found here.
In recent years I have had the great privilege of being involved with a great group called Academic Women in Public Administration (AWPA). AWPA is a network of academic women in public administration seeking to address gender issues in the field. They organise some great events, provide information about upcoming roles and opportunities in the field and mentoring opportunities. They also have some good GIF game if you follow them on Twitter (@AWPArocks).
Through AWPA I had the pleasure of virtually meeting the wonderful Mary Feeney who is an Associate Professor at Arizona State University. We got talking about some work she had done looking at journal leadership and gender equity and decided we would develop this into a journal article. We were joined by Lisa Carson who is a fantastically talented post-doctoral fellow with us at the Public Service Research Group and the resulting publication has just appeared in Public Administration Review. The abstract for this is reproduced below:
Journal editors serve a vital, powerful role in academic fields. They set research priorities, serve as gatekeepers for research, play a critical role in advancing junior scholars as reviewers and eventually into editorial roles, build extensive networks, and gain valuable insight into the behavior and preferences of reviewers and scholars. This article analyzes data collected from leading public administration journals in 2017 to investigate the role of women as gatekeepers of public administration knowledge. The data illustrate a clear underrepresentation of women on editorial boards. Drawing from these data, research on journal editorships, and feminist theory, the authors present a critique of the current state of public administration research and a discussion of a way forward. They conclude with a proposal for how all public administration scholars (junior, senior, men, and women), journal leadership, and academic departments can move toward increasing women’s representation in these important positions.
If you are interested in reading the paper in full then you can access this here, it is open access so you don’t need to be able to access a journal library to get it in full.
The winners of this year’s health budget are aged care, rural health and medical research.
The government has announced A$1.6 billion over four years to allow 14,000 more older Australians to remain in their home for longer through more high-level home care places. For those in aged care, an additional A$82.5 million will be directed to improve mental health services in the facilities.
The budget includes A$83.3 million over five years for a rural health strategy, which aims to place more doctors and nurses in the bush and train 100 additional GPs.
There’s A$1.3 billion over ten years for a National Health and Medical Industry Growth Plan, which includes A$500 million for new research in the field of genomics.
Other key announcements include:
– A$1.4 billion for new and amended listings on PBS – A$302.6 million in savings over forward estimates by encouraging greater use of generic and bio similar medicines – A$253.8 million for a new Aged Care Quality and Safety Commission.
Helen Dickinson, Associate Professor, Public Service Research Group at UNSW
It was well foreshadowed that this budget would bring with it significant provisions for aged care. It has been widely reported that reforms to pension and superannuation tax have resulted in disaffection in the Coalition within older age groups.
Making older Australians the cornerstone of budget measures is a calculated political tactic in a budget that in the short term makes only limited tax cuts for low- and middle-income earners.
The A$1.6 billion for 14,000 new places for home-care recipients will be welcome, but are a drop in the ocean, given there are currently more than 100,000 people on the national priority list for support.
Additional commitments around trials for physical activities for older people, initiatives to improve connections to communities and protections for older people against abuse will bolster those remaining in homes and communities.
Commitments made for specific initiatives for Aboriginal and Torres Strait Islander people and aged care facilities in rural and remote Australia will be welcomed, although their size and scope will likely result in little to address older age groups with complex needs.
While investment in aged care services will be welcome, it remains to be seen whether this multi-million-dollar commitment will succeed in clawing back support from older voters.
Recent years have seen around A$2 billion of cuts made to the sector through adjustments to the residential care funding formula. The current financial commitments go some way to restoring spending, but do not significantly advance spending beyond previous levels in an area of the population we know is expanding substantially in volume and level of need and expectation.
A number of new budget commitments have been announced in relation to mental health services for older people in residential aged care facilities, for a national mental health commission, and for Lifeline Australia.
However, given the current turbulence in mental health services, it’s unclear whether these will impact on the types of issues that are being felt currently or whether this will further disaggregate an already complex and often unconnected system.
Equity, prevention and Indigenous health
Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy at the University of Sydney
The government states its desire for a stronger economy and to limit economic imposts on future generations, but this budget highlights a continued failure to invest in the areas that will deliver more sustainable health care spending, reduce health disparities, and improve health outcomes and productivity for all Australians.
There is nothing new to address the harms caused by excessive alcohol use or opioid abuse.
The crackdown on illegal tobacco is about lost taxes rather than smoking prevention.
There is A$20.9 million over five years to improve the health of women and children – an assorted collection of small programs which could conceivably be claimed as preventive health.
There is nothing in this budget to address growing out-of-pocket costs that limit the ability of many to access needed care.
Additional funding (given in budget papers as A$83.3 million over five years but more accurately described as A$122.4 million over 2018-19 and 2019-20, with savings of A$55.6 million taken in 2020-21 and 2021-22) is provided for rural health that should help improve health equity for country Australians.
Continued funding is provided for the Indigenous Australians’ Health Program (A$3.9 billion over four years); there is new money for ear, eye and scabies programs and also for a new Medicare item for remote dialysis services.
There are promises for a new funding model for primary care provided through Aboriginal Community Controlled Health Services (but no details) and better access for Indigenous people to aged care.
The renewal of the Remote Indigenous Housing Agreement with the Northern Territory will assist with improved health outcomes for those communities.
PBS, medicines and research
Rosalie Viney, Professor of Health Economics at the University of Technology Sydney
The budget includes a notable increase in net expenditure on the Pharmaceutical Benefits Scheme (PBS) of A$1.4 billion for new and amended listings of drugs, although most of these have already been anticipated by positive recommendations by the Pharmaceutical Benefits Advisory Committee (PBAC).
Access to a number of new medicines has been announced. The new and amended medicine listings are clearly funded through savings in PBS expenditure from greater use of generic and bio-similar medicines, given the net increase in expenditure over the five year outlook is around A$0.7 billion.
In terms of medical research, there is an encouraging announcement of significant further investments through the Medical Research Futures Fund. This will be welcomed by health and medical researchers across Australia.
What is notable is the focus on the capacity of health and medical research to generate new jobs through new technology. While this is certainly important, it is as much about boosting the local medical technology and innovation industry than on improving health system performance. And the announcements in the budget are as much about the potential job growth from medical innovation as on providing more or improved health services.
There is new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs. The focus on a 21st century medical industry plan recognises that health is big business as well as being important for all Australians.
All of this is welcome, but it will be absolutely critical that there are rigorous processes for evaluating this research and ensuring the funding is allocated based on scientific merit. This can represent a major challenge when industry development objectives are given similar standing in determining priorities as health outcomes and scientific quality.
Andrew Wilson, Co-Director, Menzies Centre for Health Policy at the University of Sydney
Rural Australians experience a range of health disadvantages including higher rates of smoking and obesity, poorer survival rates from cancer and lower life expectancy, and this is not solely due to the poor health of the Aboriginal community.
The government has committed to improving rural health services through the Stronger Rural Health Strategy and the budget has some funding to underpin this.
The pressure to fund another medical school in rural NSW and Victoria has been sensibly addressed by enhancing and networking existing rural clinical schools through the Murray Darling Medical Schools network. This will provide more opportunities for all medical students to spend a large proportion of their studentship in a rural setting while not increasing the number of Commonwealth supported places.
There is a major need to match this increased student capacity with a greater investment in specialist training positions in regional hospitals to ensure the retention of that workforce in country areas. Hopefully the new workforce incentive program will start to address this.
Hospitals and private health insurance
Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University
Although the National Disability Insurance Scheme (NDIS) is relatively young, there has been much debate over how it will be funded.
Treasurer Scott Morrison recently said Labor had left a A$57 billion shortfall in funding for the NDIS. So many were left scratching their heads at the announcement that next year’s proposed increase in the Medicare levy – which was supposed to cover some of this shortfall – would be scrapped.
So how much does, and will, the scheme actually cost? Who is supposed to pay for it and why is there debate over the funding?
Calculating the costs
These are difficult questions to answer because we lack high-quality data about the extent and nature of disability in Australia. The information we do have is based on predictions, and work is underway to check these are accurate.
The case for creating an NDIS was made by the Productivity Commission in its 2011 inquiry on Disability Care and Support. The commission recommended Australia’s system of inequitable, fragmented and inefficient disability services be replaced by a new national scheme that would provide insurance cover to all Australians in the event of significant disability.
The one thing all sides of politics agree on is the NDIS represents a significant increase in disability spending, which stood at around A$8 billion per year at the time of the initial Productivity Commission report.
Original estimates suggested the NDIS would cover 411,000 participants and cost A$13.6 billion at maturity. However the Productivity Commission now estimates that around 475,000 people with disability will receive individualised support at a cost of around A$22 billion per year.
The A$8.9 billion difference between the Productivity Commission’s original estimates and the current estimate is a substantial gap. But A$6.4 billion of this difference is due to pay rises awarded to social and community services employees.
The remainder is due to the growth in the population and also the inclusion of participants over 65 years who were not included in original estimates. Once we account for these, estimates are fairly close to those originally predicted.
Last year’s Productivity Commission review of costs found the NDIS was broadly coming in on budget. Greater-than-expected numbers of children with autism and intellectual disability were accessing the scheme, but not all those with an individualised plans were able to spend their budgets.
So, for now, the NDIS seems to be tracking as intended. The NDIS budget is estimated to gradually increase over time to 1.3% of GDP by 2044-45 as participants age. Estimates also suggest the scheme will produce benefits adding around 1% to the GDP.
Where the money comes from
The original Productivity Commission report suggested the federal government be the single funder of the NDIS and that revenue to support the NDIS be paid into a separate fund (the National Disability Insurance Premium Fund) to provide stable funding for the scheme.
The Productivity Commission suggested this approach because disability services have long been subject to debate about who should bear the costs of these services: the Commonwealth or the states and territories. Indeed, part of the reason for the NDIS was to guarantee funding for disability services and stop these debates and blame-shifting.
The way the NDIS is funded is complex, with revenue coming from a number of sources. The NDIS is funded via a pooled approach from Commonwealth and state and territory governments. The Commonwealth provides just over half of the funding for the NDIS and the rest comes from state and territories. This arrangement is governed by a number of bilateral agreements that are revisited every five years.
At the creation of the scheme, all existing money spent by various governments was directed into the NDIS to cover costs. Then, in July 2014 we saw a first increase in the Medicare levy: from 1.5% to 2% of taxable income.
Any additional funding the NDIS needs has to come from general budget revenue or borrowings.
The NDIS Savings Fund Special Account was established to collect the Commonwealth’s contribution to the scheme. This fund pools underspends or savings from across government, protecting these as a forward contribution to the scheme as it grows over future budgets.
When the Labor government originally introduced the NDIS, it said it would fund the scheme through an increase in the Medicare levy, reforms to private health insurance and retirement incomes, and a range of “selected long-term savings” including an increase in tobacco excise and changes to fringe benefits tax rules.
Labor said the combination of these revenue streams would ensure the NDIS was fully funded to 2023. But many of the savings Labor promised were intentional, rather than set in stone, and were not dedicated to the NDIS as the Medicare levy was.
It’s estimated the Commonwealth will contribute around A$11.2 billion to the NDIS in 2019. Of this, around A$6.8 billion will come from the redirection of existing disability funds and the Commonwealth’s share of the DisabilityCare Australia Fund.
This leaves an annual funding gap of around A$4 billion once the scheme becomes fully operational, accumulating to around A$56 billion by 2028.
The Commonwealth announced it would increase the Medicare levy from 2% to 2.5% of taxable income from July 2019 as a way of filling the funding gap. Estimates predicted this would raise an additional A$8 billion in revenue over its first two years.
The bill needed to do this had stalled in the Senate, with Labor and the Greens opposed. They suggested the increase should only be applied to those in higher income tax brackets.
Last week the Treasurer announced tax receipts were running A$4.8 billon higher than was estimated in December, meaning the levy was no longer needed.
For now it looks like funding for the NDIS is assured, but many within the disability community have expressed concern this does not assure funding for the long term and uncertainty may continue to prevail.
One of the great things about my role is having the opportunity to work with some fantastic PhD students. One of my current students – Aviva Kelk – is doing a PhD exploring the types of information that people with disabilities need to make decisions about care services in the context of individualised systems such as the National Disability Insurance Scheme. In all the spare time Aviva has outside of her PhD (!) she runs the organisation Clickability, an online service directory of disability services that features reviews written by people with disability.
Aviva is currently doing a survey of the kinds of information people who use and/or choose disability services need to make good decisions. If you have any insight into these issues and are willing to fill in a short survey then please see the message below. I hope to be able to follow up and in the coming months and tell you what Aviva finds.
I’m researching what information people want to help them choose disability or mental health services under the NDIS. It’s for my PhD at the University of Melbourne.
I’d love your help with a survey. It’s 11 questions. It takes about 10 minutes. Here’s the link:
Myself and Prof. Janine O’Flynn from the University of Melbourne recently recorded a podcast for Wiley Society in honour of International Women’s Day on March 8th. In this we talk about out experiences as women in academia and how societies and associations can help to improve gender parity in research fields.
The polls are predicting a hung parliament in Tasmania’s March 3 election. So it’s not surprising that key political players are starting to jockey for position. The Jacqui Lambie Network (JLN) has stepped into this fray, demanding control of the health ministry in return for providing a guarantee of confidence and support to a minority government.
“Enough is enough,” the JLN campaign page says, explaining that:
“… despite heroic efforts by our doctors, nurses and other health professionals the Tasmanian health system is in permanent crisis. It has been mismanaged by successive Labor and Liberal administrations for well over a decade and beyond.”
The JLN has a “plan to fix” this situation, but it is short on detail and unlikely to improve the health system or outcomes for Tasmanians over the longer term.
Health is an important topic of debate in Tasmania, given the state experiences some of the poorest health outcomes in the country. Tasmania suffers from high rates of chronic disease, obesity and smoking, poor nutrition, and low physical activity levels.
Many of these indicators will come as no surprise, given Tasmania struggles with high unemployment in some areas and low economic growth relative to other states and territories. Although there has been some improvement in recent years, entrenched poverty remains a problem for the island state.
The JLN makes a number of criticisms of the Tasmanian health system including: long waiting times for surgery, a lack of “properly funded and clinically staffed” hospital beds and a health system that is uncoordinated and mismanaged.
It contests that elective surgery waiting lists are “out of control”, with “Tasmanians often waiting four times longer than our counterparts across the Bass Strait”.
The JLN plan to ‘fix’ health
The plan for addressing these issues is vague, at best. The first stage is to employ the services of Aspen Medical, a private firm, which will “review” the health system and recommend ways to speed up hospital admissions and reduce waiting lists for surgery.
Aspen Medical describes itself as a “global provider of guaranteed, innovative and tailored health care solutions across a diverse range of sectors”. It has provided services nationally and internationally under contract to various levels of the Australian government, among other clients.
Further, at a time when governments are again under pressure for using too many consultants, this might not seem like an obvious choice to “save” the health system.
Following the scoping study to identify the problems in the system, in the medium term, the JLN says there will be “a special intervention by Aspen or a comparable company”.
Over the longer term, a feasibility and benefit study into a new public and private health centre will be completed, with the aim of building a new hospital located on a greenfield site in a central location on the North-West Coast.
Will this work?
It’s unlikely to make a difference. Both the starting point and the solutions offered aren’t quite right.
The state of the Tasmanian health system is not as dire as Lambie and colleagues make out. While it is true that Tasmania has traditionally performed badly in terms of waiting times for surgery, successive improvement plans have had some impact.
Recent figures on the performance of public hospitals show that in 2017, 90% of those on the waiting list were seen within 300 days, down from 450 days the year before.
More than half of those on the waiting list were treated within 41 days in 2017, down from 60 the previous year and only a few days above the national average of 38 days.
This is not to say that there is no further room for improvement. But the process of turnaround seems to be in place. Hard working clinical professionals should be supported to continue these gains, rather than simply just abandoning wholesale the approaches adopted.
Building a new hospital may alleviate some of the pressures that Tasmania faces; although the idea that there is an “ideal” site to situate a hospital is fanciful at best and will likely encounter challenges of those who live close to a hospital at present.
But the more worrying part of this plan relates to the fact that it treats hospitals as the most important part of the health care delivery infrastructure. Much of the international literature on health systems suggests a need to move away from hospital-centric models of service delivery.
As developed nations encounter growing numbers of people with chronic and complex illness, we need to enhance community and primary care to most effectively and efficiently serve this population’s health needs. This is even more pressing in contexts of socioeconomic disadvantage. Investing in preventative care is a way to improve patient outcomes and, over the longer term, slow growth in health funding increases.
The evidence shows that Tasmania spends significantly less than other states on public health interventions. By simply focusing on waiting times and hospital admissions, the JLN is missing an important part of the health system. In effect, this plan is seeking to treat the symptoms and not the cause.
This post originally appeared on the blog of the Australian and New Zealand School of Government, you can find this here
An ANZSOG-funded research project is exploring the increasing use of robots in care services to replace or complement the roles of humans. In this article, the team of researchers explores some of the long-term implications for governments from the rise of robots.
The rise in number of citizens needing government-provided care services and advances in technology make it inevitable that robots will play a far greater role in care services, including services most of us will access at some point in our lives (e.g. education and health) and those that only a small proportion of the population will access (e.g. disability services or prison).
Horizon-scanners and futurists have told us for some time that robots will play a larger part in our everyday lives and will replace some of us in our current jobs. For all the attention that these kinds of predictions have gained in the media, many of us have not seen quite the dramatic changes promised. However, a combination of forces including technological development, pressures for governments to contain costs and rising public expectations mean that we will likely see greater use of robots across many more facets of public services in the coming years. Our research examines the implications of this for the delivery of care services and the role that government should play in stewarding these innovations.
Robots are already here
Robots already have a number of applications in the provision of care services broadly defined. Applications include manual tasks such as transporting goods, meals, linens (e.g. Robocart), conducting surgery (e.g. ZEUS), dispensing medication (e.g. CONSIS), checking on residents of residential homes and sensing for fall hazards (e.g. SAM), providing rehabilitation (e.g. Hand of Hope), as learning tools in the classroom (e.g. NAO, Pepper), as a virtual assistant for the National Disability Insurance Scheme (Nadia) and also for social interaction (e.g. Zorabot, PARO, Mathilda).
Advancements in Artificial Intelligence mean that many new care applications will take on more advanced roles which aim to combine the execution of particular tasks along with social functions, where these technologies learn about individuals from previous interactions. One of the first tasks of our research project is to develop a typology of robots in care services that can provide a way of differentiating between these different technologies and their functions.
Can machines really care?
Some of the developments in care robotics will undoubtedly drive efficiencies, improve some services and outcomes for those using these. However, others may bring unanticipated or unintended consequences. As MIT Professor Sherry Turkle argues, we need to consider the human value of different care activities and whether it maintains this value if it is carried out by a machine. There is a risk that if we do not suitably consider what tasks are being substituted by technology then we could inadvertently lose some of the value in the delivery system.
As an example of these issues, the greatest recent expansion of applications in aged care is in the social domain, seeking to reduce social isolation. Robots such as Matilda are being used to engage people with dementia, through play, dancing, and making Skype calls to family members. Some of these robots have sensors so they can detect aspects of individuals’ emotions and daily schedules and use this data to interact with people in a way that is perceived as consistent with the act of caring. Other robots, such as ElliQ, aim to serve monitoring, communication and well-being purposes, that aim to keep older people living independently for longer and as a means of maintaining engagement with their family and friends.
In these applications, we believe there is a need to investigate a number of these factors in more detail. One facet of this might be the implications of surveillance in private/public geographies of care. Although it may seem a helpful development to be able to monitor people in their homes, what are some of the implications for privacy and security? Moreover, does surveillance equate to care that might be provided in situ?
There is a substantial literature arguing that care is a reciprocal activity, not simply something that is done to a person, so what might be lost if care is carried out by a machine? Additionally, we need to consider the embodied experience of touch and expression of care, and what the trade-offs are in safety and security for the cared-for in the different iterations of these arrangements.
Working to protect the rights of vulnerable groups
Many of these applications seem helpful ways to prevent social isolation in aged care and disability services, yet in other spaces there have been significant concerns expressed surrounding their application. In the US, similar technology that is being used in nursing homes to connect older people to families and friends has been rolled out to an estimated 600 prisons across the country, where in-person visits have either been significantly restricted or stopped entirely, in favor of video calls.
While the prisons cite security concerns, experts and public alike have deemed it inhumane and counter-productive. There are important differences in the prison and nursing home examples (although both constitute different forms of care). In the latter families and friends do not just Skype but physically inhabit an avatar in the same room and this is intended to supplement and not replace face-to-face contact.
Yet there are also worrying similarities, in both public framing and recipient demographics. Both groups are psychologically and physically vulnerable, and prone to social exclusion. Both groups are likely to be in need of training or therapy programs which can be mediated digitally or in-person. And while both technologies are presented to the public as a way of increasing family connection, they’re sold to the purchasers (prison and nursing home administrators, or government departments) as cost-saving measures.
There might be nothing new in this, but it means that there is an important balance to be maintained in stewarding these technologies to ensure that we can open additional avenues for social inclusion and communication, without decreasing or offering an excuse to multiply the barriers in front of physical interaction. This is where governments play an important role as stewards of technologies, developing guidelines, recommendations, and legal baselines. Our project will be a step in supporting this endeavor.
Helen Dickinson, Public Service Research Group, University of New South Wales, Canberra
Nicole Carey, Self-Organizing Systems Research Group, Harvard University
Catherine Smith, Youth Research Centre, University of Melbourne
Gemma Carey, Centre for Social Impact, University of New South Wales
I recently recorded a Podcast for the Policy Shop, which is hosted by the University of Melbourne’s Vice Chancellor – Glyn Davis on the topic of the NDIS. The other guest in this conversation (apart from my terrible cold) is Bruce Bonyhady, the former Chair of the NDIA. In this episode we discuss how this policy came to be, the scheme’s rollout, and whether the NDIS will in fact improve the livelihood of people living with disabilities in Australia. The episode can be found here.