The Victorian Council of Social Services (VCOSS) publishes a magazine called Insight, which is made available to members. This publication is focusedon 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.
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.
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.
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.
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.
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.
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.
Last week I had the pleasure of going on the program Life Matters on Radio National to discuss the NDIS. I was part of a panel brought together to discuss the roll out of the NDIS, some of the successes to date and some of the challenges now and in the future. I was joined on the panel by two wonderful people – Leah van Poppel of the Youth Affairs Council of Victoria and Kevin Stone of the Victorian Advocacy League for Individuals with Disability.
We had a great discussion of the NDIS and its impacts on disabled people that involved research, advocacy and consumer perspectives. You can catch the version of the discussion here.
Last week we had our public launch with a debate titled ‘what makes us healthy’. The event was hosted by Julie McCrossin, and guest speakers included the Disability Discrimination Commissioner Alastair McEwin, performer Emily Dash, and journalist and appearance activist Carly Findlay, speaking about their personal experiences of health and happiness. It was a great launch and if you missed it there is a great write up of the event and the centre’s approach on the Power to Persuade site written by Celia Green and Zoe Aitken and you can find this here. Croakey also republished this piece with pictures of the event and some tweets from the audience here.
Co-lead for the CRE-DH, Professor Anne Kavanagh was busy in the run up to the event writing pieces for the Australian on Pauline Hanson’s suggestion that children with disabilities should be excluded from mainstream schools, link for this is here. Anne also did a piece for Pursuit on the new CRE-DH, which can be found here.
If you are looking for a research role there is a postdoctoral fellow in health inequities being advertised by the University of Sydney and you can find the advert here. Stay tuned for more updates about this exciting initiative.
We have been doing a lot of promotion of the research we did funded by the Melbourne Social Equity Institute into the National Disability Insurance Scheme of late. One of the things we had the chance to do was to present at the Victorian Parliamentary Library. Myself and two of the community researchers presented the findings and took questions from an audience including a number of MPs from the Victorian government. Other community researchers joined us in the audience and took part in the discussion that followed.
In addition to having a wonderfully beautiful library, the librarians are very adept with knowledge translation via social media and have produced a short video clip on our research. You can find this here (if you can bear to look at my face for a few minutes).
The National Disability Insurance Scheme (NDIS) is “on track in terms of costs”, according to a position paper released by the Productivity Commission this week. The report further stated that:
if implemented well, it will substantially improve the well-being of people with disability and Australians more generally.
But the Commission’s paper also expressed some significant concerns at the speed the scheme is being rolled out, and that this could undermine its overall effectiveness. The report highlighted a number of areas that are proving challenging for those accessing the scheme. It noted that such barriers to access are, in fact, contributing to keeping the costs on track.
As a result, the government asked the Productivity Commission to undertake an independent review into the overall costs of the scheme, its value for money and long-term sustainability. The full report is due by September.
The current position paper goes to great lengths to acknowledge the size of the challenge in delivering the NDIS. It argues that the
scale, pace and nature of the changes it is driving are unprecedented in Australia.
When fully implemented, the scheme will involve the delivery of individualised support to 475,000 people at a cost of A$22 billion per year.
There is no doubt the NDIS is complex, but the Commission finds that there is “extraordinary” commitment to the success and sustainability of the scheme. It notes that making the scheme work is not simply the job of the National Disability Insurance Agency (NDIA), but also that of government, participants, families and carers, providers and the community.
Based on the data collected, the Commission finds NDIS costs are broadly on track with the modelling of the NDIA. A greater number of children are entering the scheme than expected, leading to some cost pressures, but the report notes the NDIA is putting initiatives in place to help deal with these challenges.
The report also finds benefits of the NDIS becoming apparent, with many, but not all, NDIS participants receiving more disability support than previously and having more choice and control.
Problems with the scheme
Many people who are dissatisfied with the scheme have reported they couldn’t find care providers to deliver their funded and approved plans. This kind of under-utilisation of services is a factor contributing to keeping costs on track. Such findings are in line with recent independent research into consumer experiences of the scheme.
Overall the report finds there is insufficient flexibility in the NDIA’s operational budget and that money could be spent more in a way that reflects the insurance principles of the scheme, such as greater amounts of funding being invested in prevention and early intervention services.
The process of care planning needs greater attention. Pressure on the NDIA to get numbers of people on to the scheme means that the quality of the care planning processes have been decreased in some cases. This has caused “confusion for many participants about planning processes” and has resulted in poor outcomes for them.
There is a significant challenge in relation to the disability care workforce. The Commission estimates that one in five new jobs created in Australia in the next few years will need to be in the disability care sector. The report notes that current approaches to generating greater numbers of workers and providers are insufficient.
A range of responses required to address these include a more targeted approach to skilled migration, better market management, and allowing formal and informal carers to provide paid care and better price monitoring and regulation.
The interface between the NDIS and other disability and mainstream services has also proved problematic. There is a lack of clarity in terms of where the responsibilities of different levels of government lie and who should be providing which services. Some people with a disability have lost access to supports they used to get as state government disability services close down.
Need for political will
The Commission describes the roll-out to the full scheme as “highly ambitious” and expresses concern it risks not being implemented as intended. Indeed the speed of the NDIS roll-out is described as having “put the scheme’s success and financial sustainability at risk”.
The report concludes that if the scheme is to achieve its objectives there needs to be a
better balance between participant intake, the quality of plans, participant outcomes, and financial sustainability.
The NDIS is taking a number of steps to deal with these issues but the Commission “is unable to form a judgement on whether such a refocus can be achieved while also meeting the roll-out timetable”.
What all of this means is that we will need to see some enormous political will to enable the scheme to be supported to reach its full potential. This will likely involve some slowing of the timetable for implementation and some difficult work to deal with a number of the areas that have been identified as problematic. Whether the government has an appetite to see this through remains to be seen.
This week two articles on the National Disability Insurance Scheme have made it to early view with Social Policy and Administration. Both deal with important aspects of the scheme drawing on data collected with a variety of different stakeholders from across the system.
The first with Catherine Needham, compares the introduction of individualized budget policies for people with disabilities in Australia and England. Data is drawn from semi-structured interviews undertaken in Australia with politicians, policymakers, providers, disability rights groups and care planners, along with analysis of policy documents. This data is compared to the authors’ earlier research from England on the personalization narrative. We argue that the National Disability Insurance Scheme (NDIS) currently being introduced in Australia deploys an insurance storyline, emphasizing riskpooling and the minimizing of future liabilities. This contrasts with the dominant storyline in England in which attention has focused on the right to choice and control for a minority of the population. This difference can be explained by the different financial context: the NDIS needed to build public and political support for a large increase in funding for disability services, whereas in England the reforms have been designed as cost-neutral. Tensions in the English narrative have been about the extent to which personalization reforms empower the individual as a consumer, with purchasing power, or as a citizen with democratic rights. We conclude that Australia’s approach can be characterized as a form of social investment, evoking tensions between the citizenship of people with disabilities now and the future worker-citizen.
The second is with colleagues at the Public Service Research Centre on the topic of market stewardship in the NDIS. We argue that personalized care and market-based approaches to public service provision have gained prominence in a range of Organisation for Economic Co-operation and Development countries. Australia has recently joined this trend, launching a complex and expansive programme of individualized care funding for disability through the National Disability Insurance Scheme. Public sector markets (i.e. where governments either directly fund a market by way of competitive tendering, or through personal budgets) have been embraced by actors at different points of the political spectrum and for a range of reasons, including efficacy and efficiency gains, empowerment of citizens and efforts to cater for diversity. Despite the growing dominance of public sector markets and individualized funding, many questions about the role and responsibility of governments in managing and regulating these markets remain unanswered. In this article we outline different roles governments might assume in the creation and management of public sector markets, based on the types of risks governments are willing to take responsibility for. We argue that to fulfil the social contract between government and citizens, governments need to ensure that markets are properly stewarded and embedded in broader social safety nets. This, we contend, can ensure citizens receive the gains of market models while being protected from market failures or market-produced inequities.
Our research into the NDIS continues and expect more papers to follow.
Yesterday evening saw the launch of the Public Service Research Group which I lead. The press release associated with the launch is copied below.
UNSW Canberra’s School Of Business launches the Public Service Research Group (PSRG)
FOR IMMEDIATE RELEASE: Bringing together a wealth of public service experience and expertise across a broad range of disciplines and methodologies, the Public Service Research Group – launched on May 16 – uses a fresh approach to gain new insights into effective public service implementation and evaluation.
“People tend to focus on the design of policy and assume if you get that right, everything will be okay,” explains PSRG Director, Associate Professor Helen Dickinson. “We know that’s not the case and we’re more interested in the messy side of policy and public service, such as what happens around implementation, or when things don’t quite go to plan.”
Partnering with organisational clients, integral to the group’s research is that there will be a practical benefit for those who work in public service.
“We put a lot of effort into knowledge translation and making evidence more useful to practice,” says Dickinson.
Consisting of around 20 academics across the School of Government Business with backgrounds ranging from political science to health, systems theory, project management, economics, accountancy, HR, environmental studies, geography, public management, public administration and industrial relations, the PSRG has recently recruited eight experienced career researchers. The PSRG also works with an expert network of both national and international associates to ensure they have the best range of skill sets for any task at hand.
The PSRG’s inter-disciplinary, inter-methodological approach sets it apart from other research groups of its kind, with Dickinson highlighting its relevance given the changing face of modern public service.
“The reality of public services today is they’re designed and delivered by more than just the public sector,” she says. “There’s been a big expansion of contracting out services into private and not-for-profit community organisations and there’s a greater expectation that different groups and people have a say in policy-making processes. We think it’s extremely important to bring together those different sectors in the works we do, because that’s the nature of contemporary government.”
This collaborative approach also allows the PSRG to “work closely with clients to solve real issues they’re dealing with, rather than take a cookie cutter approach to research and problem solving,” explains Dickinson.
While working across a broad range of issues, the Group’s research will centralise around three themes, led by internationally renowned academics. The first, led by Dr Gemma Carey, focuses on large scale systems change and reform, the second, led by Dickinson, looks at diversity, equity and inclusion, while the third, led by Professor Deborah Blackman, focuses on public service capability.
“Those three themes, which were developed to address ongoing public service issues, encapsulate what we do, providing a practical framework for us to build on,” says Dickinson.
A few years ago myself, Helen Sullivan and Catherine Needham wrote a paper that speculated on what some of the challenges might be for the NDIS in terms of issues of accountability. In this we argued that the individual funding component of the NDIS poses a number of interesting questions about accountability. The paper considered a number of accountability dilemmas and provided evidence from different national settings to illustrate how these accountabilities may manifest in an Australian context. The paper concluded by setting out a framework of accountability bringing together these different dilemmas to think about provision of care as a whole.
In recent months we have been collecting significant amounts of data with individuals in Federal and State government exploring the tensions and challenges that have arisen as the NDIS is rolled out across the country. Over the next few months a number of new papers will come out that present this data.
In one of the first contributions myself, Eleanor Malbon and Gemma Carey revisited the paper outlined above to examine whether these types of accountability dilemmas are being realised in the early implementation of the NDIS. In the paper we outline accountability dilemmas in relation to: care outcomes, the spending of public money, care workers, and advocacy and market function. We argue that examining these accountability dilemmas reveals differences in underpinning assumptions within the design and on-going implementation of the NDIS, suggesting a plurality of logics within the scheme, which are in tension with one another.
The contribution of this paper is to set out the accountability dilemmas, analyse them according to their underpinning logics, and present the NDIS as having potential to be a hybrid institution. How these dilemmas will be settled is crucial to the implementation and ultimate operation of the scheme. No doubt this will be an issue that we revisit at a number of times over the following months.