Budget 2018 boosts aged care, rural health and medical research: health experts respond

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A$1.6 billion over four years will allow 14,000 more older Australians to remain in their home for longer.
Tanoy1412/Shutterstock

Kees Van Gool, University of Technology Sydney; Andrew Wilson, University of Sydney; Helen Dickinson, UNSW; Lesley Russell, University of Sydney; Peter Sivey, RMIT University, and Rosalie Viney, University of Technology Sydney

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.




Read more:
Infographic: Budget 2018 at a glance


Aged care

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.

It’s unclear whether this will be enough to win back older Australians’ support.
U.J. Alexander/Shutterstock

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.

We know what the best buys in primary prevention are. But despite the fact that obesity is a heavy and costly burden on the health care system, and the broad agreement from experts on a suite of solutions, this can is once again kicked down the road.

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.

The budget includes A$1.4 billion for pharmaceuticals.
Iakov Filimonov/Shutterstock

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.

Rural health

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.

The budget includes a Stronger Rural Health Strategy.
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Hospitals and private health insurance

Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University

There was no new money in today’s budget for Australia’s beleaguered public hospitals. The government is still locked in a deadlock with Queensland and Victoria, which have refused to agree to the proposed 6.5% cap on yearly funding increases from the Commonwealth. With health inflation of about 4% and population growth close to 2% the cap doesn’t allow much room for increased use due to ageing or new technology.

There is no change in the government’s private health insurance policy announced last year and nothing to slow the continuing above-inflation premium rises.

On the savings side, there was also no move yet on the private health insurance rebate which some experts think could be scrapped.

Kees Van Gool, Health economist, University of Technology Sydney; Andrew Wilson, Co-Director, Menzies Centre for Health Policy, University of Sydney; Helen Dickinson, Associate Professor, Public Service Research Group, UNSW; Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney; Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University, and Rosalie Viney, Professor of Health Economics, University of Technology Sydney

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

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Explainer: how much does the NDIS cost and where does this money come from?

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More Australians are joining the NDIS than predicted, so cost predictions have had to be updated.
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Helen Dickinson, UNSW

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.




Read more:
Turnbull government abandons $8.2 billion Medicare levy increase


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.

But this isn’t what happened.




Read more:
The NDIS costs are on track, but that doesn’t mean all participants are getting the support they need


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.

However, the increased Medicare levy doesn’t meet the full costs of the scheme – just as the levy doesn’t cover all the annual costs of Medicare. This revenue was directed into a special fund for the NDIS, DisabilityCare Australia, which is designed to reimburse governments for NDIS expenditure.

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.

Behind the funding debate

Warnings have been sounded about the NDIS’s reliance on multiple sources, fearing it creates a risk of future instability of financing.

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.




Read more:
Disability workers are facing longer days with less pay


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

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

 

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.

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.

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.

Replacing pharmacists with robots isn’t the answer to better productivity

File 20171025 5822 1wixns4.png?ixlib=rb 1.1
Pharmacists aren’t just dispensing machines.
from http://www.shutterstock.com

Helen Dickinson, UNSW

Reforming pharmacy services and the role of pharmacists is one of the recommendations made in a five-year review of the nation’s productivity, released yesterday. The Productivity Commission’s report, Shifting the Dial, highlights community-based pharmacy as a “significant unnecessary cost to the nation” and asks whether automated dispensing machines could replace pharmacists.

In recent years, community pharmacy profit margins have eroded as warehouse-style pharmacies offer lower prices and supermarkets and other retailers sell more non-scheduled medicines and complementary medicines. Some smaller pharmacy operators have questioned their viability and report feeling under threat. A number of pharmacists have already left the industry in anticipation of further pressures.


Read more: Discount chemists are cheapening the quality of pharmacy along with the price


The Shifting the Dial report argues pharmacists are constrained in offering quality health outcomes:

the availability of unproven and sometimes harmful medical products and confectionery at the front of the pharmacy is not reconcilable with an evidence-based clinical function at the back.

The Productivity Commission’s answer is automatic dispensing machines, supervised by a “suitably qualified person”. Along with the machines, pharmacists would play a “new remunerated collaborative role with other primary health professionals” where cost-effective.

These changes would mean there would be less need for the current 20,000 pharmacists around the country.

Automated dispensing

The idea of using robots to dispense drugs is not a new one, either in Australia or internationally. Automated dispensing devices have been used widely in hospitals around the world since the mid-1990s as a way of reducing medication errors, improving patient safety and decreasing costs. Over the last decade these devices have expanded into community pharmacy settings as financial pressures have driven the search for efficiencies.

Automated systems can reduce the error rate in dispensing medicines, but they also introduce different types of errors into the system too. Entering prescription details wrongly or not loading the machine correctly can have significant impacts.

Automated systems are expensive to buy so may not be cheaper over the short term, particularly when we consider the average wage for pharmacists is relatively modest. A recent government report notes:

[in] Australia, pharmacy graduates had the lowest starting salary of all industries requiring higher education training.

Given the investments required to buy automated machines it may be that not all local pharmacies have these. We may see the emergence of a hub and spoke model. This involves prescriptions coming into pharmacies, being sent electronically to a centralised dispensing hub and then returned to the pharmacy to dispense. This can be done either in person or via courier delivery.

This type of model is argued to be cheaper than the conventional system as it requires fewer pharmacists to run overall.


Read more: Robots in health care could lead to a doctorless hospital


In the UK there’s been pressure for community pharmacies to increasingly embrace automation for some time now. It’s well known their National Health Service has significant budgetary challenges and is looking for ways to save money. Plans to cut costs in pharmacy alongside commercial pressures from large chain providers, supermarkets and online prescription providers are predicted to cause the closure of up to a quarter of pharmacies.

This has, unsurprisingly, been met by significant resistance from the pharmacy profession as it challenges the existence of some jobs and will mean a move for others. But there’s good reason for others to be worried about these changes in terms of the impact on the broader health system.

Pharmacists can also offer advice on managing chronic conditions.
from http://www.shutterstock.com

The importance of pharmacists to the health system

Community pharmacists provide a number of functions that go beyond simply dispensing medications. In recent years we’ve seen pharmacists move away from just being those who fill our prescriptions, to people with a large amount of clinical knowledge who can advise how to take medicines safely and how to manage chronic conditions.

As increasing numbers of people experience chronic illness and take multiple forms of medicines, advice on how to do this in a safe and manageable way is crucial. Pharmacists are also probably one of the more accessible parts of the health system. Many of us will have sought advice from a pharmacist about how to manage an injury or illness, or what to do with a sick child if we can’t access a GP.

We’re seeing increasing calls to embed pharmacists within primary care teams to help better manage chronic disease. With growing numbers of individuals living with chronic disease and taking medication, pharmacists can play an important role in educating and advising on medication management.

This could improve medication use for consumers and reduce errors for those with chronic disease. Making greater use of pharmacists could reduce demand for GPs and other more expensive health professionals. For over a decade, pharmacists in the UK have been able to complete additional training that allows them to prescribe medication, helping to address shortfalls in the GP workforce.

Although the Productivity Commission report envisages a new role for a smaller pharmacy workforce, there’s little detail on what this might look like. And it underestimates the role pharmacists play within the broader health system.

If the changes outlined in the commission’s report are realised you might have your prescriptions dispensed by a robot in the future. But, it’s unlikely this will make a huge impact on the overall efficiency of the health system, and we would lose some of our most accessible clinical professionals in the process.

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

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

How is the NDIS faring so far?

Last night I went on the ABC Radio show Nightlife to discuss how the NDIS is faring so far, a few months after the national roll out started.  The show was hosted by Philip Clark and I was joined on the panel by Fiona May, CEO of ACT Disability, Aged and Carer Advocacy Service.  We discussed why the NDIS came about, what some of the impacts have been and what needs to happen in the future.  A number of callers joined us with their perspectives for the second half of the show.

If you missed it you can catch the show here.