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.

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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.

Life Matters

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.

 

 

Launch of the Centre of Research Excellence in Disability and Health

I have written before about the fact that I have the great pleasure to be involved in an NHMRC-fundedCentre of Research Excellence in Disability and Health (CRE-DH).  This is the first of its kind internationally and is Australia’s new national research centre to improve the health of people with disabilities.

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.