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Generational Health Review - Final

Country: 
Australia
Partner Institute: 
Centre for Health, Economics Research and Evaluation (CHERE), University of Technology, Sydney
Survey no: 
(2)2003
Author(s): 
Rob Anderson, Marion Haas
Health Policy Issues: 
Public Health, Prevention, System Organisation/ Integration, Political Context, Funding / Pooling, Quality Improvement, Benefit Basket, Access, Responsiveness, HR Training/Capacities
Reform formerly reported in: 
South Australia Health Review
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Abstract

The Final Report of the South Australian Generational Health Review, 'Better Choices Better Health', justifies the case for systemic reform of the South Australian (SA) health system. The report's 74 recommendations aim to create a health system which is: focused on population health and health inequalities; primary care based; more accountable; and more capable of effective change.

Purpose of health policy or idea

The Final Report of the South Australian Generational Health Review (GHR), Better Choices Better Health, justifies the case for major reform of the South Australian (SA) health system, and makes 74 specific recommendations that together aim to create:

  • a population health approach
  • a primary health care focused system
  • greater accountability and transparency
  • workforce development
  • a focus on health inequalities and health as a human right
  • effective change management and implementation

 

[Full Report (pp.283) and Summary available under "GHR Report", at: http://www.health.sa.gov.au/sahealthreform  or http://www.sahealthreform.sa.gov.au]

The Full Report of the Generational Health Review (GHR) was published in April 2003.  Another document, "First Steps Forward - South Australian Health Reform", was launched by the SA government shortly afterwards (June 2003) to outline initial reform plans in response to the GHR, including the establishment of an Office of Health Reform within the Department of Human Services.  A joint press release by the Premier of SA and SA Minister for Health claimed that First Steps Forward provides "immediate action" on two thirds of the GHR's recommendations.  On the 1st of September, a second First Steps Forward (FSF) policy paper outlined an implementation process for moving to New Governance arrangements [Both the First Steps Forward and First Steps Forward - New Governance (FSF-NG) policy papers are available from the web sites above]

Since the GHR was intended to be a blueprint for reform over the next 20 years it is grounded in an analysis of some of the big issues currently facing all health systems, especially an ageing population and the shifts in the burden of disease this will create.  The development of the strategy also acknowledges: the social determinants of health; increasing and sometimes unrealistic consumer expectations (often in relation to new medical technologies); existing imbalances in the funding and geographical distribution of hospital services.

Main points

Main objectives

To summarise and analyse the current problems facing the South Australian health system, and the health of South Australians (i.e. to present the case for change)

To "deliver a plan to the Minister for Health [of SA] that provides effective strategies for health system reform, which ensures that all South Australians enjoy the best possible health and have access to high standards of health care" (Source: Terms of Reference of the Review)

Type of incentives

Currently these documents do not contain any explicit incentives for health policy reform: they are strategic policy documents with an emphasis on prioritising problems and establishing a strategic direction, declaring guiding principles and call for the development of more specific strategies in relation to particular issues.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent rather system-neutral system-neutral

As a strategic policy document, the ideas for change are - taken together, and in the Australian context - bold and radical.  The process of change implied is however consensual and incremental, recognising the need to provide access to quality care whilst major change in the health system is occurring.  It makes a strong case for change, based on a comprehensive and highly critical analysis of the current structure and operation of the South Australian health system.  It also clearly defines some new goals, the new institutional structures and roles that should achieve them, and establishes community participation as a key driver for change.

Political and economic background

See Survey #1, and:

South Australia has a population of about 1.5 million (~8% of Australia's population), of whom about three-quarters (1.1 million) live in the State capital Adelaide.  Like Australia as a whole, most of the population live in towns or cities near the coast.  With a land area of 984,377 square kilometres, South Australia is almost three times the size of Germany, over four times the size of the UK, and over six times the size of California . (Sources: South Australia at a glance 2002, Australian Bureau of Statistics. Downloadable from http://www.ausstats.abs.gov.au, and http://wonderclub.com/Atlas/world.htm).

With regard to the various arguments for health system reform, SA's population is ageing at a faster rate than other Australian states and territories (with the major exception of the indigenous (aboriginal) population: their median life expectancy of 51 years is 26 years shorter than for the rest of the population).

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Origins of health policy idea

The current wave of reports and initiatives are an explicit response to the Generational Health Review, and follow many of the specific recommendations of the Review.

Approach of idea

The approach of the idea is described as:
renewed: It follows a Review of the NSW Health System (2000-2001), which also had John Menadue as the Chair of the Review team (NSW Health Council)

Innovation or pilot project

Else - The report contains a number of local 'case studies', both to illustrate problems with the current health system, and as examples of possible solutions.

Stakeholder positions

The Final Report of the South Australian Generational Health Review (GHR), Better Choices Better Health, justifies the case for systemic reform of the South Australian (SA) health system, to create a system with:

  • a population health approach
  • a primary health care focused system
  • greater accountability and transparency
  • workforce development
  • a focus on health inequalities and health as a human right
  • effective change management and implementation

 

The GHR itself was based on an extremely wide consultation with a range of stakeholders, especially through written submissions about discussion papers.

By announcing the division of Adelaide into two Regional Health Service areas, but delaying the 'process of cooperative reform' of SA's rural and remote areas (until after a Country Health Summit, to be held 24 October 2003; FSF-NG, p.4).

Influences in policy making and legislation

Although changes to legislation are being drafted, it is still unclear exactly which pieces of legislation will be changed.  However, initial changes to legislation will apparently include those to formalise community participation in various levels of health planning.

Also, some existing legislation - the South Australian Health Commission Act 1976 - will allow the SA Health Commission to be 'revitalised' (FSF-NG, pp.12-13).

(The GHR did not emerge in response to any changes in legislation.)

Adoption and implementation

The Premier and the Minister of Health of SA has stated that the government accepts the GHR's analysis of the problems within the SA health system, and will develop a health reform strategy based on this analysis and implement many of the Review's recommendations.

The First Steps Forward document points to the drafting of new legislation and the creation of new institutional structures, and the establishment of an Office of Health Reform within the State's Department of Human Services.  A second First Steps Forward policy paper on the processes for implementing New Governance arrangements maps out the key relationships, roles and responsibilities that will need to be created or fostered.  This includes the development of constitutions for some of the new institutions, and the expectation that some of the Boards will dissolve themselves by early 2004 (FSF-NG, p.4).  However, as discussed below, there are already some potential contradictions between planned actions and the Review's recommendations.

Some timelines have been established: ten 'primary work areas' have been defined for action to take place within the next 18-24 months (from August 2003).

Monitoring and evaluation

The revitalised SA Health Commission "will have a specific role in independently monitoring and reporting on the roll out of the health reform agenda" (FSF-NG, p.12).  The early establishment of an annual reporting system for hospital performance would provide an opportunity to monitor the success of some aspects of the Strategy.

Expected outcome

The policy document is highly critical of the current structure and operation of the health system in SA, particularly in relation to the fragmentation and duplication of planning, funding and governance arrangements, and its inability to focus on the development of population health and primary health care.

The document strongly declares that legislative changes are required, particularly to change governance arrangements within the State health system (particularly to clarify roles and responsibilities and incorporate genuine community participation), and refocus on population health.  The new 'regional governance model' should enable:

  • Planning for defined geographical populations (at the sub-State level)
  • A population approach to health funding (i.e. health budgets based upon the need-adjusted population size to be served)
  • Statewide population service planning (e.g. optimum configuration of high cost and complex services)
  • Population-based health governance (i.e. more transparent and inclusive decision-making, greater accountability to the local community, as well as the ongoing participation of local communities who have financially contributed to health facilities, and continue to do so)

According to the GHR (i.e. a policy recommendation - not policy per se) the new population focused model will, critically, replace the South Australian Health Commission Act 1976, and the dissolve the incorporation of the existing '76 health units'.

In summary, as a strategic policy document, it is bold and radical.  It makes a strong case for change, based on a comprehensive and highly critical analysis of the current structure and operation of the South Australian health system.  It also clearly defines some new goals, and the new institutional structures and roles that should achieve them.

However, the First Steps Forward paper (June 2003) provides mixed evidence about whether the bold proposals might get 'watered down'.  On the one hand, the SA Government repeats their commitment to creating a regional health structure (including two health regions specifically for the city of Adelaide), developing a population-based system of funding health services, establishing a 'State Clinical Senate' (to advise the State's department of Human Services on clinical planning priorities, safety and quality, use of new technology etc.), and establishing an annual system of Report Cards for hospital performance.  But, the establishment of a Regional Health Structure will now be in negotiation with existing health unit boards.  The idea of abolishing the 76 health units appears to have been abandoned (or at least postponed; in fact, in rural SA, an explicit commitment to "no forced removal of local boards" has been made).  Also, the SA Government has pledged that "no hospital will close and no hospital will be privatised".  (Although it would be unwise to assume that the ordering of issues in a policy document closely reflects a Government's actual priorities, the stated commitment to developing primary health care came after its commitment to "sustaining and developing hospitals".  However, it should be noted that public hospitals are the main component of the Australian health system over which the eight States and Territories' have direct control and the most visible public responsibility).

Similarly, the planned creation of the State Clinical Senate - a body of 20 first class health professionals - to advise on a range of directly clinical but also some less directly clinical issues (service delineation, workforce policy, health technology assessment and priority setting) implies a dominant reliance on doctors as the best informed advisers on a range of issues throughout the health system.  The GHR's original recommendation was for the Clinical Senate to advise on 'clinical planning' and the development of statewide quality and safety standards but its terms of reference now seem to encompass broader aspects of health system planning.

While the SA Generational Health Review is strongly grounded in the health policy challenges of an ageing population, there are no plans for action that are specifically related to these challenges.  Most of the proposed First Actions are system-wide and - with the exception of children, Aboriginal people, and people with mental illness - there are as yet few initiatives directed at particular population groups or health needs.

Recently, John Menadue, who was the chair of the SA GHR (and also of a major review of the health system in NSW in 2000-2001) has suggested the following main elements for successful health system reform in Australia (see Med J Aus, 6 October, 2003 Vol. 179, pp.367-369):

  • A 'Commonwealth/state health commission' should be established in any state that agrees to cooperate with the federal government in the joint funding and operations of public healthcare services in that state, to "break the wasteful impasse and buck-passing of the present divided system".
  • The roles of ministers, health executives, boards and health institutions, particularly in the states and territories, must be clearly defined.
  • There must be close linkages between corporate, clinical and community governance, and "clinical governance in the end must be subject to corporate governance".
  • To change the health agenda "major and successful communication" is needed to establish the community's clear priorities in healthcare spending.
  • Health leaders must acquire and demonstrate proven capabilities in managing change in large organisations.
  • Major workforce renewal is required in the health sector, to make productivity gains and improve job satisfaction.
  • An all-of-government approach, at the highest level, to tackle the most pressing social and economic determinants of poor health (in Australia, this need is greatest for Aboriginal people)

It is far too early to predict how successful this ambitious reform plan might be, or how closely the South Australian government will follow the detail and underlying principles of the Review's recommendations.

References

Sources of Information

The Final Report, the Summary, or the SA government's related First Steps Forward policy papers are all available at:

http://www.health.sa.gov.au/sahealthreform  or http://www.sahealthreform.sa.gov.au

John Menadue, the Chair of the Review process, gave a keynote address about possible ways forward for health reform in Australia at the Australian Health Care Summit 2003.  This has since been published in the  Medical Journal of Australia (2003, 6 October issue, Vol. 179, pp.367-369) http://www.mja.com.au/public/issues/179_07_061003/contents_061003.html

Reform formerly reported in

South Australia Health Review
Process Stages: Idea, Pilot

Author/s and/or contributors to this survey

Rob Anderson, Marion Haas

Suggested citation for this online article

Rob Anderson, Marion Haas. "Generational Health Review - Final". Health Policy Monitor, October 2003. Available at http://www.hpm.org/survey/au/a2/2