|South Australia Health Review|
|Implemented in this survey?|
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.
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:
[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.
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)
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.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
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.
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).
|Implemented in this survey?|
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.
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)
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.
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:
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).
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.)
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).
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.
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:
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):
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.
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
|South Australia Health Review|
Process Stages: Idea, Pilot
Rob Anderson, Marion Haas