Information requirements when choosing and using disability services

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.

 

Hi there, 

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: 

https://www.surveymonkey.com/r/ndis-info

People with disability, family members, carers, support workers, LACs, and anyone else who’s involved in choosing services are invited to respond. 

Feel free to shoot through any questions. 

Thanks!

Aviva Beecher Kelk

avivabk@student.unimelb.edu.au

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Don’t underestimate the power of representation

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.

 

You can find the full recording here.

Why the Jacquie Lambie Network’s Tasmanian health plan doesn’t add up

 

Helen Dickinson, UNSW

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.




Read more:
Tasmanian election likely to be close, while Labor continues to lead federally


 

The state of the Tasmanian health system

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.




Read more:
Public hospital blame game – here’s how we got into this funding mess


 

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.




Read more:
Infographic: a snapshot of hospitals in Australia


 

Debates have rumbled on for years about the lack of hospital beds in Tasmania and whether the health system is underfunded. It may be true that there is a need to increase capacity of hospital beds in the state. But this alone will not deal with the health system’s challenges.

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.




Read more:
Focus on prevention to control the growing health budget


 

Helen Dickinson, Associate Professor, Public Service Research Group, UNSW

This article was originally published on The Conversation. Read the original article.

‘You don’t know what you’ve got ‘til it’s gone’: The implications of expanding the use of robots in care services

This post originally appeared on the blog of the Australian and New Zealand School of Government, you can find this here

Paro with a dementia patient

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).

Since at least the 1970s, many countries have experienced significant changes in relation to care services. Groups needing care services are increasing in numbers, becoming older, have greater levels of disability and chronic illness and higher expectations about the quality of services that should be delivered. At the same time, care services are finding it increasingly difficult to recruit appropriate workforces.

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. NAOPepper), as a virtual assistant for the National Disability Insurance Scheme (Nadia) and also for social interaction (e.g. ZorabotPAROMathilda).

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

Image credit: The Toronto Star

Taking the pulse of the NDIS

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.

Public Service Research Group Paper Series

At the Public Service Research Group we recently launched our paper series, one of the ways we propose to communicate about our research.  This series offers research-based thinking about topical themes for the public service. The PSRG paper series comprises two different forms of articles – Research Briefs and Issues Papers

Research Briefs

Research Briefs are short papers that summarise the findings and implications of a recent piece of PSRG research.  The intention is that these should be short and accessible summaries that set out some of the practical implications of recent research findings.

Briefing Paper No.1, November 2017 – Embedding Gender Equality in the Australian Public Service: Changing practices, changing cultures   (The full report of Changing Practices, Changing Cultures is available here.)

Issues Papers

Issues Papers are more substantial pieces that are an original exploration of a theme relevant to public services.  These papers provide an account of the state of the art evidence and issues around an important theme for contemporary public services.

We recently launched two of these papers:

Issues Paper No.1, November 2017 – Not Another Review About Implementation? Reframing the Research Agenda

Issues Paper No.2, November 2017 – Is All Stewardship Equal? Developing a Typology of Stewardship Approaches

 

These papers received some significant media coverage including in the Canberra Times (on the topic of context and implementation) and the Mandarin (on the topic of stewardship and gender equity).  If you are interested in my speaking notes from the evening that summarise the various things we have been doing this year you can find these here – Paper Series Launch notes 29.11.2017.  As you can see from this it is has been a busy year so I’m off for a break and back some time in the new year.

How can we think about stewardship?

The concept of “stewardship” is increasingly being looked to as a driver of contemporary public service practice in Australia, and elsewhere. The diversity of contexts in which stewardship has arisen suggests a concept that is capable of broad application to achieve many outcomes. But, how can we meaningfully identify and understand stewards and their role in contemporary public policy?

The concept of “stewardship” is rising in prominence as a driver of contemporary public service practice in Australia and internationally. The Productivity Commission recently described it as being core to the reform and delivery of human services in Australia; the Commonwealth Superannuation Corporation identifies it as the crux of the trust relationship with its members and the Australian Future Fund has adopted it to guide its long-term asset strategy. The Department of the Prime Minister and Cabinet describes its entire role in stewardship terms.

Although stewardship might seem like a new term in a public service context, it is, in fact, one that has been around for some time and has been applied in diverse ways over the years. In this article we provide some clarity around the concept of stewardship, drawing on our recent research.

Defining stewardship

Reviewing the academic literature reveals at least three universal features of stewardship models. First, definitions or descriptions of stewardship invariably involve a steward taking responsibility for some object or cause to the benefit of others.

Second, stewardship is adopted when resources are constrained. Restricted resources, include environmental, financial, personnel and informational. In some cases, stewardship is required because individual actors do not recognise that the resource is constrained. For example, an individual might not consider their carbon emissions to be a problem, but collectively, emissions have significant consequences for the climate system.

The third common factor shared across definitions of stewardship is that of abeneficiary. Beneficiaries can be clearly identifiable as a group within the community, such as participants under the National Disability Insurance Scheme, or they can be of a more indeterminate character, such as the whole community (to varying degrees) in the case of environmental contexts where ecosystem services, such as clean air and water, are stewarded.

If we examine the literature carefully, we can distinguish between the outputs and outcomes of stewardship. Stewardship outputs are actions driven by a need or desire to achieve an outcome that might need to endure beyond, or operate independently, from a defined policy goal. Stewardship outcomes comprise measurable change/s in at least one of the three universal stewardship components as a result of the stewardship outputs: (1) resource constraints: constraints on a resource are measurably reduced or eliminated; (2) beneficiaries: measurable increase in benefits to beneficiaries; and (3) responsibility: individuals or groups take on a (greater) level of responsibility for a resource, cause or process.

Typology of stewardship approaches

From our research, we developed a typology of stewardship approaches, comprising four composites, each viewing the role and means of stewardship in different ways. These types are not intended to be understood as individuals, per se, but rather are collections of individuals who share beliefs about the purposes and activities of stewardship approaches. It is possible that a number of these different types could be present in any given stewardship setting.

The Guide

Remains responsible for the resource on behalf of the beneficiary

The Guide is defined by a position of responsibility in relation to constrained resources that inevitably means making decisions of compromise. An example of this is a government agency tasked with allocation of public funding in a manner that seeks to achieve fair and equitable distribution of resources while best meeting the objectives of the community. The Guide approach is particularly driven to ensure accountability. The Guide is likely to operate at large scales and set goals over long temporal periods (e.g. government departments with broad responsibility for achieving reduce climate emissions).

The Gatekeeper

Grants access to privately held or controlled resource

The Gatekeeper will have direct control over a resource but will not typically be involved in policy-making processes. Engagement with these actors is necessary to meet policy objectives (e.g. landholders engaged in environmental conservation, private company that controls a publically important resource, or a hospital with good community relationships). Governments (often acting as the Guide) would seek to work with these kinds of stewards to gain access to these resources, but would often not seek to hold the resource directly. The Gatekeeper often operates on local scales and observes success over shorter timescales.

The Giver

Makes a sacrifice for the ‘greater good’ that increases the value or abundance of a resource

The Giver is motivated by a desire to make a contribution by means other than financial or direct reward. In contrast to the Gatekeeper approach, ‘the Giver’ actively seeks to sacrifice individual benefit for that of the collective. Through such a sacrifice, they can effectively extend the resource base (e.g. augmenting payments or delivering service beyond what is required). As with Gatekeepers, the Giver approach typically operates on a local scale, although the giving may be towards a globally significant goal. Such a perspective is likely to favour shorter-term goals, where efforts can be seen to make a positive contribution but can also lead to longer-term collective goals. It is possible that the Giver and Gatekeeper approaches are adopted concurrently.

The Maximiser

Distributes resources for maximum efficiency, utility and benefit of the collective

The goal of the Maximiser is to create “collective benefits” outside of any concept of ethics, volunteerism or sacrifice. This approach might involve processes to help improve the efficiency of allocating resources within a system, attempting to reduce duplication or overlap between public and private resources to achieve greater ‘bang for buck’. For example, this type of approach might be used to generate multiple community health benefits by designing education programs that simultaneously appeal to different sectors. Such a perspective also seeks to identify co-benefits by strategic allocation of resources. In doing so, a Maximiser perspective is not wedded to a particular temporal or spatial scale, but works according to context.

We offer that this typology can be a useful tool in identifying the purposes, beneficiaries and levers of stewardship when developing such an approach (Table 3, see full Issues Paper for more detail). The typology can be a helpful resource to use with stakeholders to discuss the aims and objectives of any stewardship approach and help to identify where potential challenges might arise in terms of different stewardship initiatives conflicting with one another during implementation processes.

Strengths and weaknesses

The below table summarises the strengths and weakness of stewardship approaches as well as the dominant object of stewarding and levers.

  The Guide The Gatekeeper The Giver The Maximiser
Strengths Overarching, powerful Controls the resource Strongly motivated by social levers Fiscally responsible
Weaknesses Politically sensitive, changeable, high level Competing priorities No direct resource access Motivated to externalise costs
Dominant object of stewarding Outcome (change)

Process

Output (action) Output (action) Outcome (change)

 

Dominant levers Administrative Legal Social Economic

Adapted from ‘Is All Stewardship Equal? Developing a Typology of Stewardship Approaches’ by Dr Katie Moon, Dr Dru Marsh, Dr Helen Dickinson, Dr Gemma Carey from the UNSW Canberra Public Service Research Group.

Withdrawing funding for hosptials’ mistakes probably won’t lead to better patient care

File 20171128 2004 800q96.jpg?ixlib=rb 1.1
If you get an infection in hospital, they’ll receive less funding for your care under a new plan. Presidencia de la República Mexicana/Flickr, CC BY-SA

Helen Dickinson, UNSW

Update: I also did a radio interview with 2SER on this article and the podcast can be found here

The Commonwealth government has just announced a change in the way they fund hospitals, effectively withholding part payment where patients have avoidable complications. The initiative aims to improve the quality of hospital care and reduce overall costs, but without other measures, this probably won’t do much to stop hospital-acquired complications from occurring.

The new plan for hospital funding

Public hospitals are funded by an activity-based system in which they receive money for the services they deliver. Diagnosis-related groups are used to classify hospital episodes of care into a number of codes, which are then reimbursed at amounts set by the Independent Hospital Pricing Authority.

Complications that occur during hospital care, and where there is good evidence these could have been reduced through clinical risk mitigation strategies, are known as hospital-acquired complications. These include things like surgical complications, pressure injuries, falls and health care associated infections.

If you experience a hospital acquired complication then the complexity of your care is likely to increase and you may stay in hospital for longer. This means the cost of care for this treatment goes up. Estimates suggest where you have a health care associated infection the cost of your care increases by 9%, renal (kidney) failure by 21% and malnutrition by 7%.

Pricing Framework for Australian Public Hospital Services 2018-19

From July next year, if you experience a hospital-acquired complication, the hospital will get a reduced rate of funding for that care. Of course, the chance of you developing a hospital-acquired complication will depend on a number of characteristics (such as age and the reason you’re in hospital), and not just the quality of care you receive.

So the amount of money the hospital loses is determined using a risk adjustment model. Assessment against a range of characteristics determines whether an episode of patient care is low, medium or high in terms of complexity, and this score is used to determine the funding reduction.

If a patient is at low risk and experiences a hospital-acquired complication, the hospital will receive funding for that person’s care reduced by the full incremental cost of the hospital-acquired complication. If a patient is at high risk then the funding for that episode of care will be reduced by a proportion of the incremental cost of the hospital-acquired complication. The new policy builds on a change to funding systems that was introduced in July, which withdrew funding for serious errors (so-called “sentinel events”).


Read more: Punishing medical errors won’t improve hospital safety or quality


Why this approach is being introduced

It’s estimated that for the years 2014-15 and 2015-16, there were just over 101,000 and over 104,000 cases in Australian hospitals of hospital-acquired complications, respectively. So the money spent on these cases could have been put to other uses across the health system. The Independent Hospital Pricing Authority estimates A$280 million will be saved by introducing this policy.

The idea is this scheme will mean hospital managers and staff work harder to ensure they avoid these issues occurring. The scheme is not designed to eliminate hospital-acquired complications entirely – this would be very difficult to achieve in a complex system like a hospital.

But the intention is the threat of losing some funding should drive processes of improvement. The resulting impact for those receiving hospital care can be significant if it means you avoid a significant or traumatic complication that compromises your health.

What could be some of the negative impacts of the approach?

The challenge with this type of approach is we don’t know whether pay for performance works. It’s widely debated, but on the whole hasn’t achieved the expected gains in health effectiveness and safety.

Where should we use robots in care services?

Rarely a day goes by without a story in the media about robots and the various threats and opportunities they pose to various aspects of our day-to-day life.  The Public Service Research Group has recently been awarded a research grant by the Australia and New Zealand School of Government to investigate the use of robots in care services and the implications for government in stewarding these technologies.  Led by myself and Gemma Carey, this project also involves Catherine Smith (Melbourne Graduate School, University of Melbourne) and Nicole Carey (Self Organizing Systems Research Group, Harvard University).

The good folk over at The Mandarin have published a piece from us today on this project (you can find it here).  If you are interested in finding out more about this project or potentially being a case study then please get in touch with us.

Innovation funds and impact investing

The Victorian Council of Social Services (VCOSS) publishes a magazine called Insight, which is made available to members.  This publication is focused on finding ways to end poverty and disadvantage and making the clear case for change.  It explores important themes and features research, ideas, analysis and commentary from leading thinkers and practitioners on social justice. Insight is published three times a year by VCOSS, with national editions in collaboration with the Australian Council of Social Service (ACOSS).

In the latest issue I have a piece on innovation funds and impact investing that explores some of the different models being used to drive change across Victoria and internationally.  The piece describes some of these different methods and the evidence of their effectiveness and concludes on a note of caution about these approaches and their ability to ‘solve’ complex problems.

The article – and others in the issue – can be found here.