|Implemented in this survey?|
Over the past 20 years, government sponsored health compliants mechanisms have emerged in Australia. The development of these bodies illustrates the rising power of health care consumers and concurrent loss of autonomy for health professions. Across Australia, there are important differences between the juisdictions in the way each body has developed and how it carries out its work. Recent events in NSW illustrate the differences between conciliatory and a prosecutorial approaches.
The objective of each Federal and State based health care complaints body is to resolve complaints made by eligible persons in respect of health services. Their common characteristics are that they are:
The incentives operating here are:
The expected outcomes of the work of these bodies are that health care providers and organisations are seen to be accountable for their actions and an improvement in the standard of care delivered to patients. The work of the various complaints bodies affects both those individuals associated with complaints (complainants and those against whom the complaint is made), the facilities and organisations in which the complained-about event took place and, potentially, the health system as a whole.
The objectives of the health complaints bodies are to:
consumers, providers, legal profession
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
This is an unusual Australian-based "experiment" in creating community responsive accountability for standards of health care. It is innovative in providing for independent statutory bodies which
can decide on how to investigate, assess, conciliate or take appropriate legal action to resolve a complaint made by a patient about an individual or facility providing health care.
At the time of introduction, it was a controversial idea, particularly in the eyes of providers. Controversy still exists amongst those working in the area over the relative merits of conciliation (the emphasis adopted by most States and Territories) versus prosecution (adopted as a major strategy by the NSW HCCC).
It is not clear that the work of the complaints bodies has had a system-wide effect, although their presence may modify the behaviour of individual providers depending on how concerned she or he is about a complaint or litigation.
The complaints bodies only become visible to the public if their investigations are reported. This usually occurs when a complainant is not satisfied with the outcome of the investigation, particularly when a need is perceived for an individual or facility to be "punished" and this has not been seen to occur.
There is no reason why this system could not be adopted in other health care systems, particularly in countries where the office of an ombudsman-type official is well-known.
The first statutory body specifically for health care complaints was set up in NSW in 1984 followed by Victoria (1988), Queensland (1991), the Australian Capital Territory (1994),
Western Australia (1996), Tasmania (1997) and the Northern Territory (1998). South Australia is the only state that does not currently have a separate statutory body although a bill has been
intorduced into parliament and health consumers can complain to the SA Ombudsman's office.
However, before 1993, there was a lack of uniformity in the health care complaints structures in place in Australia. The level of protection available to an individual depended on the State or Territory in which she or he was resident. Under the Medicare agreements (1993-1998), the Commonwealth struck agreements with the States/Territories for the development of Public Patients' Hospital Charters and the establishment of independent complaints mechanisms. So, although the States took the initiative in developing these bodies, the Federal government was sufficiently interested to make the provision of funding (under the Medicare agreement) partially conditional on all the States and Territories establishing and maintaining complaints mechanisms. However, there is still variation between the complaints bodies in terms of their organisation, capacity and funding arrangements.
|Implemented in this survey?|
The Australian approach to complaints mechanisms does not appear to be a common one. Although most countries with developed health care systems have processes for receiving and dealing with
patients' complaints and complainants have recourse to the legal system of the country in which they reside, Australia, New Zealand, Sweden and some states of the USA are alone in adopting an
independent ombudsman-type of system.
The emergence of the health complaints bodies in Australia in the 1980s was a response to both international and local issues. International issues such as a growing consumer rights movement demanding greater accountability from providers and rising costs from litigation and compensation payments were also felt in Australia.
In a number of States, major scandals led to public demands for better systems of accountability. In each case, malpractice and/or negligence resulted in multiple deaths and the medical and bureaucratic response proved inadequate in dealing with the events.
Recently, the NSW Health Care Complaints Commission has come under scrutiny in relation to allegations of malpractice and poor systems of quality assurance and accountability in one Area Health Service. Although the NSW HCCC has historically persued a prosecutorial agenda, it had recently moved away from this approach towards a conciliation approach. However, its report on the alleged malpractice issues, where emphasis was placed on the faults within the system and not on individual medical staff at fault, did not please the government who dismissed the Commissioner and appointed a lawyer to head an inquiry into the HCCC inquiry. This clearly indicates a return to the prosecutorial agenda.
Governments and consumer advocates/interests formed an alliance to develop the complaints bodies and the powers which they have at their disposal. The creation of the complaints bodies was
universally opposed by the Australian Medical Association (AMA). The formation of the bodies indicates that the demand for greater accountabilty has been shown to have more sway than the
self-regulation, (such as peer-review and the use of Medical Registration Boards to impose standards and disciplinary procedures) which was proposed by the medical associations.
The length of time the complaints bodies have been in existence may indicate a high level of support within the community and amongst professional groups. However, as seen recently in NSW, once an investigation undertaken by a complaints body is a source of interest to the media, their work is open to attack by both the medical and legal professions if their approach is seen not to conform with the one preferred by a particular group; ie if they adopt a conciliatory approach where a prosecutorial one is preferred (legal profession) or if the blame does not fall on those individuals seen to be at fault (medical professions). In the recent NSW case, following the "failure" of the NSW HCCC to adequately deal with a large number of complaints, a member of the legal profession was asked to adjudicate. However, subsequent to its first report (the Walker inquiry) the NSW HCCC was asked to re-examine the cases which had caused the scandal in the first instance. Although this may ultimately result in the complaints being resolved, the drawn-out process keeps the spotlight away from any under-resourcing of the either the health care system and/or the HCCC as well as delaying any resolution of the issues to the satisfaction of either patients and their families or the health professionals involved.
The formation, function and powers of all the complaints bodies are underpinned by specific legislation. As far as can be ascertained, these pieces of legislation have not been modified since the inception of each of the complaints bodies.
Politicians, consumers advocates and health professionals were all involved in the negotiations which led up to the formation of the health complaints bodies. They would also have been involved in
any lobbying of members of parliament about their support or opposition to the legislation.
Since their implementation, each of the complaints bodies has become a well-recognised part of the Australian health care system. However, their function can be seen to have been compromised by a number of issues with which they have been forced to deal.
First, in the opinion of all the complaints bodies, they have been under-resourced. Second, they have been required to, on the one hand, increase the accountability for standards of health care (which has the potential to increase the amount of litigation instigated) and, on the other, reduce the amount of litigation (and the costs of compensation) by acting as an alternative source of dispute resolution.
Governments may have an incentive to not guarantee funding for the complaints bodies. Control over funds increases the likelihood that the complaints bodies will have to request additional funds for major investigations. Such investigations may not be in the interest of governments who (in the form of the health department) may be one of the agencies investigated.
Each of the complaints bodies collects data about the number and type of complaints received and the way in which they were resolved. In December 2000, approximately 42,000 complaints had been
recorded by the complaints bodies across Australia. Over a period of 10 years, the quality of treatment (including diagnosis, treatment and medication) led to 35% of all complaints. Other categories
of complaint included access (13%), communication (12%), professional conduct (11%), privacy/discrimination (9%) and cost (9%). Medical practitioners were the most complained against profession (74%)
but nurses attracted only 1% of complaints against individual providers.
Each complaints body also submits an annual report to parliament which details its achievements against objectives. However, while the rising number of complaints might lead to the conclusion that their presence is necessary and has contributed to consumer empowerment, there is little evidence that their existence has resulted in any imporvement in the quality of health services.
In Australia as a whole, two means have been used to evaluate the work of the complaints bodies. In 1997, co-operation between the bodies led to the establishment of the National Health Complaints
Information Project which produced the Inaugural National Health Complaints Data Collection. The project was closed down in 2000.
In 2004, the 4th National Health Care Complaints Conference will be held. At the 3rd conference, held in 2001, the concurrent sessions and workshops covered such issues as patients rights, effectiveness of complaints processes, conciliator's workshop, data collection and dissemination, complaints resolution - alternative processes and complaints officers and risk management.
It can be seen from these topics that the evaluation, has to date focussed on the structure and process of the complaints bodies indicating that there is room to evaluate the outcomes of their work in terms of increased accountability, decreased litigation and increased quality of care.
As mentioned above, it seems difficult to reconcile the objectives of increasing accountability with decreasing costs due to litigation and any resulting compensation. It seems likely that the
overall effect of the complaints bodies would be to marginally affect quality of care and access to care but at an increased cost to the health system.
In contrast to the suspicion their formation roused amongst health professionals, the complaints bodies now enjoy a reasonable level of support amongst these groups. This may be due to the emphasis on conciliation as a means of resolving disputes as well as the low number of major investigations into major instances of malpractice.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
There is little or no evidence that the existence of health care complaints bodies has any impact on the quality of care, equity or efficiency of the health care system. To date, evaluations have focussed on the processes involved in the complaints area.
Thomas D. 2002. Medicine called to account: health complaints mechanisms in Australasia. No.93 ASHSA, University of NSW, Australia.
Thomas D. 2004. Health system flounders as complaints bodies defend their agendas. www.smh.com.au/text/articles/2004/04/01 Accessed 5/4/2004
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Office of the Health Services Commissioner (Victoria). www.health.vic.gov.au/hsc Accessed 5/4/2004
The Australian Capital Territory Community and Health Services Complaints Commissioner. http://184.108.40.206/hcc Accessed 5/4/2004
Health and Community Services Complaints Commission (Northern Territory). Objectives and Powers. www.nt.gov.au/omb_hcscc/hcscc/powers.htm Accessed 5/4/2004