Chapter 2 The healthcare delivery system
Mastery of content will enable you to:
• Define the key terms listed.
• Discuss the main factors influencing healthcare reform.
• Discuss some of the challenges of indigenous health and the strategies to improve outcomes.
• Describe key aspects of Medicare and understand the notion of a safety net.
• Discuss the key elements associated with access to the healthcare system.
• Describe primary, secondary and tertiary levels of care.
• Differentiate between primary care and the philosophy of primary healthcare.
• Describe the financing of your country’s healthcare system.
• Discuss the key issues of healthcare related to rural and remote areas.
• Discuss the role of nurses in different healthcare delivery settings.
Healthcare systems continue to experience rapid change, as they have done since the mid-1980s. Healthcare expenditure in real terms has risen consistently over this period. In both Australia and New Zealand, the proportions of health expenditure to gross domestic product are similar and consistent with most other countries in the Organisation for Economic Cooperation and Development (OECD), with the exception of the United States where the proportion of GDP is higher but health outcomes poorer across the population. Although life expectancy has risen in these countries, ethnic and socioeconomic disparities give rise to differences among groups within each country, and we will see evidence of this for the indigenous populations of both Australia and New Zealand.
Healthcare systems are located within the wider sociopolitical and economic framework of countries, and thus need to be viewed within these contexts. The differences between how Australia and New Zealand have approached healthcare delivery are based in part on the way the government systems of each country are organised and the values of the constituents expressed through their political choices. In Australia there is a federal–state split in healthcare service provision; New Zealand has one national government organising healthcare services for the entire country.
This chapter broadly covers the Australian and New Zealand healthcare systems and their evolution. Other chapters discuss in more depth some of the topics raised in this introductory chapter.
Discussion in this chapter covers:
It is important to understand the developments leading to the creation of the current Australian healthcare system. In 1788, 700 convicts and approximately 560 guards and officials landed at Sydney Cove. On disembarkation, the colony’s first medical service was established, comprising nine naval surgeons, four of whom were commissioned for medical service to the new settlement. Two medical officers who were surgeons’ mates were also part of the first medical service. Tents were erected to care for the sick, but were soon overflowing and unable to deal with the number of patients. The first dispensary store was built at that time and eight convict hospitals were established, each with a ward for troops and a separate ward for convicts (Sax, 1984).
Conditions were appalling, the mortality rate was 10% and malnutrition and dysentery were rampant. By 1791 there were 600 patients under care, financed by funds from the English Treasury, thus providing a free service. Military personnel ran the service but military and naval surgeons did not attend confinements, as emancipists and free settlers were not regarded as their responsibility. Hardship was common in this group, so the Benevolent Society of New South Wales was formed in 1818 and offered food, clothing and fuel to help those suffering hardship.
The first hospital grew from the origins of the Sydney Dispensary, founded in 1827, and functioned as an outpatient service mainly for the poor. It was renamed The Infirmary in 1845 and became Sydney Hospital in 1848 (Sax, 1984). The convict hospitals were transferred to civilian boards of control over this period, out of direct government control, and consequently the first hospital boards appeared. They were aggressively independent, funded from voluntary appeals for capital funds and maintained by subscriptions, fees and subsidies from government. In the late 1840s, medical practitioners and companies established private hospitals for wealthier clients. Religious groups also began to provide services and in 1857 St Vincent’s Hospital, Sydney, was established. It is interesting to see the seeds of a public and private system even from the country’s earliest days.
The first friendly society, Manchester Unity, began in New South Wales in the 1830s. This was an attempt by working men to meet the cost of medical care. Individuals contributed a membership fee and in return were provided with medical attention and medicines. Friendly societies became very popular, peaking just before World War I (Sax, 1984), when about a third of the population received medical cover through them. Medical practitioners were at first agreeable, but gradually hostility grew because they were paid a fixed annual sum negotiated with the society. The medical practitioners objected to being subservient to non-professional employees. They also objected to the societies being open to high-income earners and resented the variable levels of capitation fee paid by different societies. By 1909, the NSW Branch of the British Medical Association (BMA) was successful in persuading governments to set limits on access to and availability of friendly societies. After World War I the medical practitioners succeeded in overturning the contract systems, ensuring that fee for service would be the only method of payment. As a result of this, fees increased and low-income workers left, jeopardising the viability of the friendly societies. As independent professionals, medical practitioners were now regulating their own practice, ensuring a high-status profile in the community. The political power of the medical profession has a long history of influence over healthcare decision making in Australia, and these activities are the genesis of this substantial power base.
With federation in 1901, the Commonwealth government provided resources for welfare state activities, including health insurance. The medical practitioners were determined that the English-legislation system of capitation payments would not be introduced, as they clearly saw the threat to their potential income. A Royal Commission was held in 1926, which produced the National Health Insurance Act 1928; however, the Act was not implemented until 1938. Later, the Pharmaceutical Benefits Act 1944 was passed, but medical practitioners viewed it as controlling their professional discretion and they continue to be vocal even today about what is included and excluded from this scheme. These are two landmark pieces of legislation and the bases from which the Medical Benefits Schedule and Pharmaceutical Benefits Scheme have arisen (more about them later).
In 1951 a Pensioner Medical Scheme was introduced to help people with special needs obtain healthcare. The Medical Association drew up the Health Insurance Act 1953. This Act provided a subsidised contributory insurance scheme administered by private agencies, with medical practitioners being paid on a fee-for-service basis. By the late 1960s, however, it was apparent that there was inequality in the distribution of medical and hospital services.
Perhaps the most radical reforms relating to funding and provision of public health were initiated after the Whitlam Labor government came to power in 1972 (Duckett, 2007). Medibank, a universal health insurance scheme, was introduced in 1975 to provide a health safety net for all Australians. It was funded directly by taxation.
The Whitlam government’s policies reflected recognition of the many elements that affect the health of individuals and families, including housing, education, family support, nutrition and employment, and you will come to know this concept as the ‘social determinants of health’. These elements had been well documented but by and large ignored by previous governments, save for the occasional attempt at the integration of services. By contrast, the Hospitals and Health Commission established by the Whitlam government was charged with establishing a network of integrated services with primary care as the cornerstone (Duckett, 2007). Interestingly, but somewhat discouragingly, this remains the objective of the similarly named National Health and Hospitals Reform Commission (Bennett and others, 2009), which is the blueprint for the latest reforms in Australia, nearly three and a half decades later.
In 1975 the Liberal government revoked Medibank and returned to a private insurance system. In 1983, with the return of the Labor government, a slightly changed and slightly differently named system was introduced in which Medibank became Medicare. The newly named Medicare introduced controls on private healthcare agencies. By now, many people were confused by the constant changes; the medical profession challenged the state hospitals and Medicare legislation and in 1985 the government negotiated a plan that left the Medicare legislation in place but made concessions to medical practitioners. This system is still in place, but the fundamental dispute regarding who controls the system is still not settled. Duckett (2007:xvii) captures this in the opening words to his book on the Australian healthcare system: ‘The Australian health care system is … a contested terrain, characterised by conflict over values and policy choices.’
In the recent past, policies have focused on illness in the acute care context, but there is recent acknowledgment of the burden of chronic illness on families and the community and the need for more community-focused, community-based care, preventative, restorative and caring for chronic ongoing conditions. The Commonwealth Department of Health and Ageing, or DoHA as it is known, initiated the National Health and Hospitals Reform Commission in 2008 and its final report was presented to the Minister for Health, Nicola Roxon, in June 2009. In the executive summary the Commissioners said:
The case for health reform is compelling … While the Australian health system has many strengths, it is a system under growing pressure, particularly as the health needs of our population change. We face significant challenges, including large increases in demand for and expenditure on health care, unacceptable inequalities in health outcomes and access to services, growing concern about quality and safety, workforce shortages, and inefficiency.
Further we have a fragmented health system with complex division of funding responsibilities and performance accountabilities between different levels of government. It is ill-equipped to respond to these challenges. (Bennett and others, 2009: executive summary.)
The report then proceeds to identify actions for reform under three reform goals:
• Tackling major access and equity issues that affect health outcomes for people now;
• Redesigning our health system so that it is better positioned to respond to emerging challenges; and
• Creating an agile and self-improving health system for long-term sustainability.
In the access and equity area there were five priorities. Unsurprisingly, improving health outcomes of Aboriginal and Torres Strait Islander people was number one and this was followed by issues related to mental health, rural and remote support, dental care and timely access to quality care in public hospitals.
System redesign included embedding prevention and early intervention, integrating health and aged-care services, and reshaping Medicare to better account for health promotion, early intervention and chronic disease management.
Long-term sustainability was to be enhanced through strengthened consumer engagement and voice; a ‘modern, learning and supported workforce’; improved data, information and communication; better funding models; and ‘knowledge-led continuous improvement, innovation and research’.
From the early days of European settlement in New Zealand, a mix of providers offered healthcare services: the government, voluntary and ‘for-profit’ sectors. The healthcare system was based on the English model familiar to the new settlers, including its Poor Laws that mandated local responsibility for the poor.
Medical practitioners worked independently and were paid directly by their patients. Public hospitals were established to treat those who could not afford medical and nursing care in private hospitals or their own homes, those who had no homes or those who needed care or incarceration including in ‘lunatic’ asylums. As hospital treatment became more effective, the middle classes increasingly used and paid for care. While some towns and districts financed their hospitals, as did some voluntary organisations, others found it impossible to maintain sufficient public support, and by the 1880s the government funded all hospitals (Royal Commission on Social Policy, 1988:43).
Public health boards previously had been set up in provinces and districts. The Public Health Act 1900 created a Department of Public Health headed by a Chief Health Officer, while those appointed as local district health officers were to be medical practitioners with ‘special knowledge of sanitary and bacteriological science’ (Royal Commission on Social Policy, 1988:44). New Zealand (earlier than other countries) thus set up a national department of health to oversee the health of the population. The Department of Public Health gradually took on broader functions, merging with the Department of Hospitals and Charitable Aid in 1909 and eventually being renamed the Department of Public Health in 1920 (Dow, 1995).
By the mid-twentieth century, hospitals had become the key component in the healthcare system. Advances in medical knowledge and technology meant that hospitals were able to offer effective treatment rather than just care, and caring for seriously ill people at home ceased to be the norm. The organisation of hospitals also changed as they expanded and became more costly. Government funding gradually increased, while patient fees made up an increasingly smaller share of revenue (Royal Commission on Social Policy, 1988:45).
The first Labour government of New Zealand (1935–49) substantially shaped the healthcare system of today, setting up a welfare state in the years following the worldwide depression of the 1930s. The Social Security Act 1938 marked the introduction of a comprehensive healthcare system that mandated the provision of free care for all. Universal entitlement to tax-financed and comprehensive healthcare was established; free hospital treatment was provided for all (including mental hospitals, maternity hospitals and sanatoria); medicines were made free; and the government subsidised the cost of medical care. General practitioners insisted on remaining independent, however, and after lengthy negotiations were subsidised by the government on a fee-for-service basis rather than through patient capitation payments or salaries. Their view was that the subsidy attaches to the patient and is not a payment by the government to the practitioner.
Some services, such as dental care and optometry, were still paid for privately; by 1947, however, New Zealand had set up a predominantly tax-funded healthcare system that made most services available free to the user at the point of delivery, with mixed public and private provision. A government review in the early 1970s noted that health services had developed in a fragmented way and could not be described as a comprehensive national healthcare system. In the late 1970s, the Minister of Health set up a Special Advisory Committee on Health Services Organisation to advise on ways to integrate the array of health services. The committee’s recommendations resulted in the Area Health Boards Act 1983 which provided the basis for establishing local boards, initially elected and later composed of both elected members and those appointed by the Minister of Health, to plan and manage the delivery of health services for their area (Royal Commission on Social Policy, 1988:46).
From the centrally funded and managed model of the 1940s, New Zealand’s healthcare system gradually changed to a more devolved structure in the 1970s and 1980s with hospital boards having greater autonomy, and later to area health boards (AHBs) which appointed their own chief executives. Thus the changes that occurred in the early 1990s with the move to regional health authorities (RHAs, described below) was not made from a highly centralised system but rather from one that was already substantially devolved.
The centralised ‘welfare state’ healthcare system was decentralised in the mid-1980s when the Labour government elected in 1984 proceeded to regionalise health services. Area health boards were formed in the mid- to late 1980s, their population catchment areas varying from 35,000 to 900,000, with each area being organised around at least one large district hospital (Organisation for Economic Cooperation and Development, 1994:230).
The Department of Health maintained responsibility for subsidising primary care and for services delivered by ‘national’ providers, while the AHBs were responsible for secondary and tertiary healthcare (mainly hospitals) and public health services. The new boards funded their own hospitals and other health services, and were charged with consulting the community and with undertaking area needs assessments. The government set national guidelines and closely supervised their activities. The Department of Health initially allocated funds to the 14 boards partly on an historical basis, but from 1983 used a population-based formula and exerted some control by capping hospital expenditures. AHBs thus became the main health service authorities, being allocated around two-thirds of the government budget (Ashton, 1995).
Between 1983 and 1993, the New Zealand health sector was thrown into chaos through successive restructuring (Laugesen and Salmond, 1994; O’Brien, 1989). The government environment at this time was not conducive to a top-down approach to solving health issues; that is, centralised workforce planning and interventions were deemed to be appropriate only when the market was seen to be failing or barriers needed to be overcome (Salmond and others, 1994).
In the early 1990s, the National government introduced a devolved system of healthcare provision, often referred to as the ‘funder–provider split’. In 1992, a short-lived and highly unpopular attempt was made to provide a disincentive to people using hospital services, rather than primary care services, by enabling AHBs to charge for some services. In addition, in 1993 the Department of Health became a Ministry, with the devolution of most operational activities to 23 Crown health enterprises (CHEs), This also signalled a major philosophical change, with CHEs being structured as ‘for profit’ agencies with funding provided through the four RHAs. A separate Public Health Commission was established, subject to the Health and Disability Services Act 1993.
In 1997 the Labour–Alliance coalition government again reformed the structure of the healthcare system. In 1998 the four RHAs became a single health funding agency (HFA). The 23 CHEs became 24 health and hospital services (HHSs) subject to the Health and Disability Services Amendment Act 1998. The role of the Ministry of Health was also redefined.
Further reforms were introduced by the Labour–Alliance coalition in 2000, with the introduction of the New Zealand Public Health and Disability Act 2000. An increasing focus on the role of primary healthcare, and in achieving universal access to primary care services, was marked by the release of the New Zealand Primary Health Strategy in 2001. In 2003, the Ministry commenced its implementation of primary health organisations (PHOs), with the aim of changing primary healthcare services from a fee-for-service basis to capitation funding for those organisations.
In 2008, a National government was elected. The term of that government has been reflected in an emphasis on reducing costs and achieving savings throughout the entire public sector, including the health sector. This approach can be partly attributed to the international financial environment, but it also reflects a genuine desire on the part of the government to achieve savings, as well as the unforeseen outcomes of the 2010 and 2011 Canterbury earthquakes and the November 2010 Pike River mining disaster; each of which has had a significant economic impact.
Major healthcare reforms under the National government have been reflected in the catch-phrase ‘Better, Sooner, More Convenient’ and by the establishment of six national health targets against which DHBs are monitored. A separate part of the Ministry of Health, Health Workforce New Zealand, was established to focus on current and future workforce needs and to consider how those needs might best be met. Like other government departments, the Ministry of Health has experienced significant cuts to staffing.
The backdrop to the healthcare reforms in Australia and New Zealand over recent decades was the international rise in healthcare expenditure. This caused general concern and a focus on cost-containment, and had led to major reforms in health services in several other countries, including Britain, Denmark and most recently the seemingly immoveable United States. Several reasons for this rise have been suggested, including a general ageing of the population (causing an increased demand for healthcare), technological developments (which increase costs, such as laparoscopic surgery and diagnostic aids), and general expectations that the latest treatments will be made available (improvements in communication disseminate this knowledge more widely than in the past, with the internet changing patient behaviour markedly). Despite a wide variation in approaches to reform, by the 1990s and the first decade of the 2000s all developed nations were struggling with the financing and delivery of healthcare (Palmer and Short, 2010).
The philosophical basis on which the Australian and New Zealand healthcare systems are designed mandates that all citizens have access to healthcare regardless of socioeconomic status. Under the current healthcare system, anyone may be seen by a general medical practitioner, or attend a hospital’s emergency department or community health service and expect to be seen. The issue of access is separate, however, from the issue of payment, which is discussed later, and even access is becoming a contested area as the geographical disparities in access grow.
The funding of the Australian healthcare system has historically been a matter of negotiation between the Federal Minister and the State Ministers, as we have seen above. The broad brushstrokes of the system, such as Medicare, are set federally but the functioning of the hospital systems has until recently been seen as the business of the states. State governments have taken a variety of political and philosophical approaches to healthcare reform, from the radical experiences in Victoria of the early 1990s to the subtler but none the less profound changes of Queensland and New South Wales (see websites of the state Departments of Health for details). In 2010, following the National Health and Hospitals Reform Commission report (Bennett and others, 2009), the federal government proposed a radical reform of the interactions between themselves and the states in an attempt to get rid of the divide of services that saw patients funded for part of their journey of illness and recuperation by many different sources. At best this was confusing to the patient, and at worst was expensive and cumbersome with all sorts of incentives for both ‘sides’ to try to shift costs to the other. The Ministers of Health at state and federal level meet regularly in a forum called the Council of Australian Governments (COAG) to discuss their coordinated planning and working. In February 2011 their deliberations were of particular significance, as they outlined the latest reform actions:
On 13 February 2011, at the Council of Australian Governments meeting, the Australian Government and all states and territories signed a Heads of Agreement on National Health Reform.
Under the Heads of Agreement, the Australian Government will increase its contribution to efficient growth funding for hospitals to 45 per cent from 1 July 2014, increasing to 50 per cent from 1 July 2017. A guaranteed additional $16.4 billion will be provided by the Australian Government under this new agreement up until 2019–20. This funding is on top of the level of funding that the Government would have otherwise provided.
Governance of the health and hospitals system will devolve to new local institutions—Local Hospital Networks (LHNs) and Medicare Locals. Reform of the front end to aged care will commence, working with LHNs and Medicare Locals. This will ensure care is coordinated at the local level across the acute, primary health and aged care sectors.
COAG has agreed to the establishment of a national approach to activity based funding of public hospital services and that these will be funded, wherever possible, on the basis of a national efficient price for each public hospital service provided to public patients. An independent hospital pricing authority will be established to determine the efficient price for public hospital services.
All governments will contribute funding for hospitals into a single national pool which will be administered by an independent national funding body. There will be complete transparency and visibility of government contributions into and from the pool. As well as amounts paid to LHNs, funds will flow from the pool to the states and territories for block funding for small regional and rural hospitals and to fund teaching, training and research undertaken in public hospitals.
A national health performance authority is also being established to develop and produce public reports on the performance of public and private hospitals and other health care services, including primary health care services such as general practice and community health services.
Additionally, the Australian Commission on Safety and Quality in Health Care has been established as a permanent, independent authority that will develop, monitor and implement national standards for improving clinical safety and quality in hospitals and health care settings.
There is also a commitment to the Commonwealth being the level of government responsible for a national aged care system, including the transfer of the Home and Community Care aged care program to the Commonwealth (except in Western Australia and Victoria where discussions continue about a potential change in responsibility for this program).
The Australian Government has negotiated these national reforms with the states and territories to ensure that the health system is put on a more financially sustainable footing, with an increasing share of public hospital costs being met by the Commonwealth into the future, more locally responsive planning and management of health services, an increased focus on safety and quality and better publicly available information on the performance of health services. In combination these reforms will improve timely access to high quality care in and out of hospital. (Department of Health and Ageing 2011–12:18–19).
This landmark statement indicates clearly the intention of these reforms and the mechanisms through which integration will take place. What we should see in the lifetime of your studies and early career is a real change in the system from the patients’ perspective, and an opening up of new community-based opportunities for your practice. This is a most interesting time in healthcare systems history in Australia. You can keep watch on this progress through the DoHA website (www.health.gov.au).
You will recall that the priority area in access and equity in the National Health and Hospitals Reform Commission Report (Bennett and others, 2009) was Indigenous health. The government has acted on this as a matter of urgency and continued the work planned through the National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH) and the Health Performance Framework through which it is reported. This framework has three tiers: health status and outcomes; determinants of health; and health systems performance. While there still remains a gap in Indigenous versus non-Indigenous life expectancy of 11.5 years for males and 9.7 years for females, and a difference in mortality of Indigenous children under 5 years of 221 per 100,000 compared with 100 per 100,000 for non-Indigenous children, which of course is cause for national action, the improvements over the past decade in many areas are noteworthy. The Aboriginal and Torres Strait Islander Health Performance Framework 2010 Report (Department of Health and Ageing, 2011) indicates a decrease in mortality rates for Aboriginal and Torres Strait Islander people living in Western Australia, South Australia and the Northern Territory of 25% between 1991 and 2008, and a decline in infant mortality of 55% in the same years. However, the report indicates a continuing concern in relation to chronic diseases, with 58% of excess deaths due to chronic disease (circulatory disease, cancer, diabetes, respiratory disease and kidney disease, particularly). The report also indicates continuing concern about smoking rates, nutrition, obesity, alcohol consumption, household overcrowding and unemployment, all of which are regarded as social determinants of health. I commend this report to you for further reading and you can keep up to date with the government response, again through the DoHA website.
The New Zealand healthcare system is predominantly publicly funded. Most healthcare is provided free of charge except primary care, where a fee for service has historically existed, but with the introduction of the primary healthcare strategy this is changing.
The National government, elected in late 1990, set up a taskforce to recommend on further structural changes along market-model lines. Its deliberations culminated in the so-called ‘Green and White Paper’ which stated as its primary objective ‘to secure, for everyone, access to an acceptable level of healthcare’. Costs had continued to increase in the health sector and the new government wished to achieve greater allocative and technical efficiency and ‘value for money’ (Ashton, 1995).
The report acknowledged the achievements of AHBs, including better management and tighter contracting, gains in technical efficiency and more community consultation. However, the reforms of the 1980s were regarded as failing to fully achieve certain policy goals, with the following problems being unresolved:
• Long and rising surgical waiting lists.
• Conflict in the role of AHBs in that they both purchased and provided services. This led to blurred lines of responsibility between boards, the communities they served and government, and incentives for boards to buy their own services rather than contract with the most cost-effective and appropriate supplier.
• Legislative constraints on AHBs which made it difficult for them to operate efficiently, for example to lease out unused space to the private sector to raise revenue.
• Fragmentation of service funding in that different parts of the healthcare system were funded in completely different ways. Hospitals were funded through the AHBs; independent practitioners by the central government on a fee-for-service basis.
• Problems with access to services. For example, there was evidence that some people on low incomes could not afford doctors’ fees.
In spite of the AHBs being democratically elected, there was a perception that more consultation and opportunities for community involvement in health service delivery were needed. A perceived lack of fairness included inconsistencies in the way healthcare was funded and subsidised and in criteria for public and private hospital treatment. The AHBs were criticised, in particular, for maintaining pre-existing patterns of health service delivery. The taskforce’s argument was that, first, incremental change had been insufficient; and, second, that a split between the purchase and provision of healthcare services was required. The AHBs were disbanded in July 1991 and two years of intensive activity followed in planning the transition to a new system (Ashton, 1995).
The Health and Disability Services Act 1993 was based on the concept of separation between ownership, purchase and provision. The Crown remained the owner and four RHAs were established (North, Central, Midland and South). The separate funding streams for general practitioner services and for hospitals and other services were merged, and each RHA was given a budget to purchase all personal health and disability services for their regional populations from both public and private providers. This integration of funding was intended, first, to reduce cost shifting between agencies and services; and, second, to make it easier to redirect resources as appropriate from institutional to community care, from secondary to primary care and from treatment to health promotion. Funding for public health services was assigned to a new body, the Public Health Commission.
This Commission was responsible for coordinating and contracting for the provision of public health services, monitoring public health and identifying areas of need in order to advise the Minister of Health (New Zealand Government, 1993:s. 28). The 14 AHBs were converted into the 23 CHE, which were to run hospitals, community and public health services. The CHEs were to function as commercial entities, being established as limited-liability companies with government shareholders, consistent with the 1986 State-Owned Enterprises Act.
The newly created portfolio of Minister of Crown Health Enterprises, and later the Minister of Finance, represented the ownership shareholding interest of the government in the CHEs. The legislation also provided for the establishment of a National Advisory Committee on Core Health and Disability Support Services (Core Services Committee) to advise the Minister of Health on the kinds and relative priorities of health services that should be publicly funded, relative service priorities and other matters that the Minister specifically requested.
It was also at this time that the Department of Health became known as the Ministry of Health. A separate operational unit of the Treasury, the Crown Company Monitoring Advisory Unit (CCMAU), also was set up in 1993, to represent the government’s interest as a shareholder in all Crown companies, which included CHEs. It advised the Ministers of Health, Crown Health Enterprises and Finance on ownership and monitoring aspects of CHEs. The advice included protecting the Crown’s investment, setting service targets and considering the impact on CHEs of proposed policies. It also advised ministers on how well the CHEs were performing against government objectives, and managed the appointment and performance assessment of company directors.
The Public Health Commission was disestablished in late 1995 (legislation enacted in early 1996), with its policy advisory function being transferred to the Core Services Committee, renamed the National Advisory Committee on Health and Disability (the National Health Committee), and its purchasing function to the RHAs.
The National/New Zealand First coalition government of 1996–99 decided that the 1993 reforms had not achieved all that was expected of them, and moved to abandon competition in favour of collaboration (Somjen, 2000). The 1996 coalition document Policy Area: Health described a healthcare system in which ‘principles of public service replace commercial profit objectives’ with cooperation and collaboration rather than competition between services. The coalition wanted to reduce administrative costs and eliminate geographical inequities. For example, the four RHAs had proved administratively expensive for a small country, while the effects of market competition could not prevail since the government had little choice but to meet the budgetary shortfalls of the CHEs (Gauld, 1999). Three of the four RHAs had accumulated substantial deficits. The incoming government shifted the focus away from a quasi-market-model approach, acknowledging that strict competition was not viable in the health sector.
The four RHAs were abolished on 30 June 1997. Their functions were transferred to a single health-funding body, the Transitional Health Authority (renamed the Health Funding Authority (HFA) on 1 January 1998) which, as a purchasing authority, continued the split between purchase and provision. The HFA contracted with a range of providers for the provision of medical, hospital, public health, disability and other health services, and was also responsible for purchasing postgraduate clinical training. Its other functions were to monitor the need for health services and to monitor the performance of providers. At the same time the CHEs were converted into the 23 HHS companies, which were relieved of the requirement to make a profit. They continued to run hospitals and related services, community and public health services, and contracted for their funds with the HFA. These companies had independent legal and financial status and continued to operate in a framework of commercial law. A 24th HHS was established to manage blood services; the only publicly owned national-level health provider. HHSs continued as by far the largest healthcare providers, receiving about half of the government health budget each year (Poutasi, 2000:141). Other providers included community trusts (including Māori health providers), voluntary sector providers (such as church-sponsored services), private ‘for-profit’ providers such as dentists, and independent general practitioners.
The portfolio of Minister of Crown Health Enterprises was also disestablished, with ownership of the oversight role being taken on by the Minister of Finance through the CCMAU. Over the next few years, however, the restructuring that had been undertaken by CHEs since 1993 continued within the HHSs. For example, Health Care Otago sold off nursing homes and small rural hospitals and cut psychiatric services in order to reduce deficits by concentrating upon its ‘core business’, which increasingly was seen as acute hospital care (Gauld, 1999).
A change of government occurred in 1999, and with this came a more hands-on approach to the health system.
At the end of 1999, the Labour–Alliance coalition government was elected on a platform that included the following: cutting waiting times for elective surgery; ensuring access to a comprehensive range of services; improving the overall health status of New Zealanders; and making hospitals non-commercial and more community oriented. The public sector market-oriented reforms of the 1990s in New Zealand were regarded as having failed to achieve their promises.
While the reforms had had some success in constraining healthcare costs, elective-surgery waiting lists had grown and the view was that structural change was needed. No real competition had emerged within regional quasi-markets and the private sector had not been stimulated to expand the range of services. Further, greater consumer choice had not emerged, and there had been little change in the distribution of healthcare providers and services, with the exception of an increased number of Māori providers (Ashton and Press, 1997; Somjen, 2000).
The health program of the incoming government was swiftly enacted under the New Zealand Public Health and Disability Act 2000, which ushered in another radical reorganisation of the health sector.
Regional governance was re-established by way of 21 district health boards (DHBs) to replace the HHSs, and the HFA was disestablished, its role being split between the new DHBs and an expanded Ministry of Health. The legislation allowed a phasing-in period whereby the Ministry of Health took responsibility for existing service contracts until the new DHBs were set up and functioning. This change ended the strict purchaser/provider split, as DHBs now held their own budgets for the services they provided but continued to purchase a proportion of their services from other agencies. CCMAU ceased to monitor health ownership, with this function being transferred to the Ministry of Health. While the move to regionalise health services had the potential for many positive gains, there were also concerns. One concern was the potential for regional inequalities to develop, and the possibility that DHBs might make commitments that they would subsequently be unable to fund. In some ways, the DHBs are similar to the old AHBs that existed in 1989 under the previous Labour government, insofar as this system returned an element of regional governance to healthcare. The fundamental difference, however, is that DHBs are responsible for both purchasing and providing services for the people of their region, including primary care. Health and disability services since 2001 have been delivered through these 21 DHBs, which act as both providers and funders of hospital and community/primary healthcare.
Under the New Zealand Public Health and Disability Act 2000, the Minister of Health is required to determine a New Zealand Health Strategy to provide the framework for the government’s overall direction of the health and disability sector in improving the health of people and communities. The New Zealand Health Strategy was developed in 2001 with 7 principles and 13 population health objectives. This provides the umbrella for the New Zealand Disability Strategy, Primary Health Care Strategy, Māori Health Strategy, Mental Health Strategy, and Pacific Health Strategy. The intention is to improve the health of all New Zealanders and reduce inequalities—40,000 nurses in New Zealand have been identified as playing a major role in delivering on these strategies (see the Ministry of Health website www.health.govt.nz).
Following the 2008 election, the National government has focused on reducing expenditure and increasing savings across the public sector. The health sector has received considerable attention in terms of the emphasis on healthcare being ‘Better, Sooner, More Convenient’, and DHBs (now reduced in number to 20) are monitored for their performance against six health targets. There is also a focus on cross-sector strategies, with all government agencies expected to develop and implement policies that contribute to the government’s strategies of Whānau Ora and Drivers of Crime. There is an ongoing focus on improving the integration of primary and secondary components of the health sector. While this is hardly a new issue, it is one which successive governments have struggled with (as far back as the 1940s), and there remains a need to clarify the role of the private secondary sector (Easton, 2002). Another hallmark of the 2008–11 National government’s approach to health has been a broad focus across communities, with significantly less focus on population groups or on disparities arising from socioeconomic status or geography than that taken by previous governments. Rather, the emphasis on addressing disparities for particular groups has tended to be addressed within the health targets, or in the component parts of individual policies or strategies. The impact of this approach has yet to be seen.
The National government has also taken a distinctive approach to the needs of the healthcare workforce, with the establishment of Health Workforce New Zealand, responsible for ‘leading and co-ordinating the development of the country’s health and disability workforce’. That agency has undertaken a range of work since its inception in 2009, including funding innovation projects, workforce service reviews and the introduction of new roles (such as the Primary Care Practice Assistant in general practices) designed to ‘free up’ the time of expert healthcare professionals.
These areas of focus outlined above have included a strong emphasis on the role of primary healthcare services. A cynical approach would contend that this focus is simply a cost-shifting exercise and there are very real concerns among primary practitioners (mainly GPs) and others that the general-practice workforce is not sufficiently well-equipped to rapidly expand its role.
Other aspects of reform include the establishment of an end-date for the Mental Health Commission (2015), following which it will merge with the Office of the Health and Disability Commissioner, and the introduction of a Health Quality and Safety Commission responsible for working with clinicians and providers of health services to improve the quality and safety of health and disability services.
Because nurses constitute the largest healthcare workforce group, their actions in maintaining healthcare quality while nursing more acutely ill patients for shorter periods of time while, at the same time, seeking to keep costs contained is pivotal to any healthcare reorganisation and the affordability and safety of the system as a whole. There is therefore a need to acquire new knowledge and skills other than those traditionally seen as ‘nursing’. These skills will enable nurses to decrease the risk of medical error and increase patient safety and the quality of care. Healthcare is costly and resources are finite. It is therefore an important nursing responsibility to know and apply business principles of transparency in decision making and accountability in the effective and efficient management of healthcare. Nurses are accountable for providing high-quality care as well as collaborating in creating systems and strategies that will ensure patients receive cost-effective and efficient high-quality care.
In order to create an affordable healthcare system that meets community needs, there has been a change in the nursing profile in Australia with the introduction of practice nurses and nurse practitioners (NPs) and the expanded role of enrolled nurses. There has been a substantial growth in the number of nurses working within general practice under the title ‘practice nurse’, and the work of these nurses with the general practitioner is supported through Medicare by the federal government. With the growing burden of chronic diseases and the ageing of the population, community care is currently focused on GP-based provision of care. The scope of practice of the second-level nurse, the enrolled nurse (EN), is expanding to try to overcome some of these complex client-care delivery issues, most specifically workforce and cost issues. ENs are now educated to be able to administer medications. However, there is a most immediate question relating to what constitutes the appropriate skill-mix for certain settings to ensure high-quality care provision. The burden on nurses of the changes in healthcare is well documented by Fagin (2008) in her paper When care becomes a burden, and the importance and consequences of safe staffing in Nurse staffing and inpatient hospital mortality (Needleman and others, 2011). These articles provide evidence-based recommendations in relation to these staffing dilemmas. In several states nurses have had to resort to industrial action to be able to assure safe staffing levels, and some states in Australia now have mandated ratios of nurse to patient.
The role of the EN has also emerged in New Zealand, with similar issues in relation to scope of practice to those experienced in Australia.
The NP role in Australia and New Zealand has been developing slowly over the last decade. In New Zealand, the development was led by government policy and regulated by the Nursing Council of New Zealand. The role is not determined by availability of positions but by approval/competency and scope of practice. New Zealand NP policy is centred on client and population needs and improving health outcomes; thus, scopes of practice are population-focused. This policy was based on research and the awareness that substantive research already exists. The competencies for NPs in New Zealand recognise not only the need for advanced clinical practice and master’s-level education but also demonstration of policy and leadership. There are currently 54 registered NPs in New Zealand, in a range of disciplines including primary health, older people’s health, neonatology and mental health. The development of the NP role in New Zealand has progressed rather more slowly than originally anticipated, particularly in some areas such as mental health. Emerging challenges include transition of nurses currently in practice into a new role, managing the concerns of the medical practitioner and raising awareness among healthcare providers and consumers about the NP role (Sheer and Goodyear, 2001). To these issues might be added the need for NPs to consider delivering their service as a business, which presents its own particular challenges.
NP roles vary in Australia according to the needs of the population/community being served, and the particular specialist expertise of the NP. For example, a community health centre in a small town may require the NP to be involved in early-childhood issues including immunisation, women’s health, emergency situations, wound dressings and postnatal care. The regulatory requirements for NP accreditation are now national in Australia, and in the recent budget NPs and eligible midwives now have access to Medicare payments, i.e. government subsidy for care. This has the potential to radically change the role the NP plays in community healthcare. The development represents a vital piece in the career structure for nurses, as it enables them to develop a career that doesn’t take them away from the delivery of direct client care. Nurses no longer need to go laterally into education or management as they progress in their careers; now expert nurses can be the ones providing direct, high-quality client care.
There have been interesting recent reports on the future of nursing and its work in the United Kingdom (Prime Minister’s Commission on the Future of Nursing and Midwifery in England, 2010) and the United States (Institute of Medicine, 2010). These have great relevance for Australia and New Zealand.
Consumers of healthcare quite reasonably want to access appropriate, cost-effective, high-quality healthcare. Society generally believes that all people have a right to healthcare. Access to care refers to the consumer’s ability to use the broad range of healthcare providers at a variety of healthcare settings. This includes general practitioners, nurses, community healthcare professionals such as allied health practitioners, and therapists who practise alternative medicine (e.g. chiropractors, naturopaths and massage therapists), and access should not be adversely affected by ability to pay or geography. Consumers also want healthcare institutions to be accountable for the quality and safety of care.
This article reports on a study on safe nursing staffing in a hospital known for its high quality of care and high nursing staffing levels. It evaluated the relationship between patient mortality and nursing staffing levels. and the effect also of high patient turnover (high numbers of admissions, discharges and transfers). It found a 2% increased risk of death each time a patient was exposed to a shift with less than adequate nursing staffing, with an average of three such shifts giving a 6% increased chance of death compared with the patient cared for with adequate staffing. Where there was high patient turnover, the increased risk of death was 4%.
The Australian and New Zealand governments are committed to encouraging a stronger, more active role for consumers at all levels of the healthcare system, and groups such as the Consumers Health Forum (in Australia) are active lobbyists in health. In New Zealand, the Office of the Health and Disability Commissioner and the Mental Health Commission have been specifically established to raise the profile of consumers, and in the case of the Health and Disability Commissioner to investigate complaints by consumers.
Any definitions of ‘consumer’ must incorporate all people from diverse cultural experiences, socio-economic status, sexual orientations and health and illness conditions, and all the diverse voices must be able to be heard. The emerging voice of consumers from the mid-1980s has been part of the backdrop to changes within the healthcare system in Australia and in New Zealand. Some of the strength of this voice has been as a result of critical inquiries into system failures (e.g. the Committee of Inquiry to inquire into the treatment of cervical cancer at National Women’s Hospital and other matters, established in June 1987). The increasingly strong voice of mental health consumers and users of disability services has also been supported by a range of inquiries, and by consumer movements worldwide. Broader sociopolitical movements including feminism and indigenous rights have contributed to the demand for consumers to be active participants in their own wellbeing.
The increasing demand by consumers of health and disability services to play an increasingly active role in decision making about service delivery and to be active participants in their own healthcare is an ongoing influence in the changing healthcare environment.
Levels of healthcare describe the scope of services and the settings where healthcare is offered to people in all stages of health and illness. In Australia the levels of healthcare are referred to as primary, secondary and tertiary.
Primary medical care is the care provided to people at their first point of contact, and as such can be provided in a variety of settings such as the general medical practitioner’s rooms or the outpatient or emergency departments in a hospital. As the first point of contact by the client, primary medical care provides a good opportunity for the doctor or nurse to identify and provide intervention for health needs and to engage in health promotion activities. There is, however, the potential for confusion in the use of the term ‘primary’ in relation to care, as there are two other frequent uses for the term. Primary healthcare is a philosophy of care which focuses on providing affordable, accessible and appropriate services for the prevention, treatment and management of disease processes. According to the World Health Organization’s World Health Report (2008), Primary health care (now more than ever), central to primary healthcare are the concepts of social justice and community participation, which include equity and responsiveness to local population health needs. This philosophy, while usually associated with community-based care, is also applicable to secondary and tertiary care environments. Primary nursing care, on the other hand, is a term used to describe a system of organisation of care, usually associated with acute care facilities where the patient is given a named nurse as the person primarily responsible for the planning and implementation of their care.
Secondary healthcare relates to the traditional acute care setting, in which clients who present with signs and symptoms of disease are diagnosed or treated. Tertiary healthcare is a level of care that is specialised and highly technical in diagnosing and treating complicated or unusual health problems. Clients who require tertiary care have an extensive, often complicated pathological condition. Tertiary settings are usually tertiary-level hospitals, where advanced expertise by medical and nursing specialists is available. Box 2-1 lists examples of the levels of healthcare in Australia.
A six-level spectrum of care—preventive, primary, secondary, tertiary, restorative and continuing care—is a useful way of organising thinking about health services. At any level of care, nurses and other healthcare providers might offer a variety of levels of prevention. The nurses working in an acute care hospital setting, for example, will monitor the postoperative recovery of a client having complex cardiac surgery while also providing health promotion information to the family concerning diet and exercise. It is important to understand how levels of care are organised and delivered and that they vary markedly from country to country.
Each level creates different requirements and opportunities for the role of the nurse. In addition, changes unique to each level of care have developed as a result of healthcare reform. There is greater emphasis placed on the importance of wellness and of primary and preventive care. More resources are being dedicated to these levels of care. Nursing has the opportunity to provide leadership in communities and healthcare systems that are aligning resources to better serve their populations.
Various healthcare services (see Box 2-2) are available to clients and families, depending on the nature and extent of a health problem and the level of care required. The types of services offered also depend on the community in which clients seek healthcare, for example city or rural.
BOX 2-2 EXAMPLES OF AUSTRALIAN HEALTHCARE SERVICES
• Screening programs (e.g. hypertension, high cholesterol levels, breast cancer [mammography])
• Mental health counselling and crisis prevention
• Occupational health and safety measures (e.g. workplace ventilation, protective eye wear, noise control)
In what ways can you imagine a broader role for registered nurses in a healthcare system based on a primary health care philosophy?
Voluntary agencies such as the Red Cross blood services and the Royal Flying Doctor transport services complement government services in Australia. Other voluntary agencies support people in attending to their activities of daily living, such as the Royal Blind Society, the Kidney Foundation and Diabetes Australia. Most voluntary agencies have an educational and health promotion role as well as providing high-quality service and care.
Non-government organisations (NGOs) are an increasingly important part of non-hospital care in New Zealand, particularly in the mental health and disability sectors. Although the value of the NGO sector is valued by governments, its growth is restricted by complex contractual and accountability requirements, often involving a number of government agencies.
Governments depend on the services provided by voluntary agencies and often give direct subsidies and/or allow tax-free donations. This approach has led to the expansion of voluntary agencies both in number and in range of services provided, but there is debate as to whether this growth is a reflection of the government absolving itself of responsibility for funding some essential components of the healthcare system.
Community nursing provides care to a wide variety of clients and includes postoperative care and intravenous therapy, for example chemotherapy or palliative care; drug therapy, such as treatment with antibiotics or insulin; medical treatments, for example for people requiring support with respiratory diseases like emphysema; and aged care. Nurses require diverse skills and are usually registered nurses (RNs), although ENs do work in the community under the supervision of RNs. Some specialised RNs, for example stomal therapists, have hospital and community roles. Often, RNs are a link between the hospital and the community. They follow up on clients at home after early discharge, for example burns patients requiring specialised dressings or patients going home on total parenteral nutrition (TPN). Australia and New Zealand both have had a long history of community nursing, for over a century. Community nursing is seen by the population and governments as an essential part of healthcare. With the reduction in the numbers of beds in public hospitals and an increase in short-stay and day-surgery cases, community nursing services require expansion and extra resources.
Early childhood services are part of child and family health services, and provide care for mothers and babies, well-baby clinics for babies with slight disabilities, and specialty clinics, for example for paediatric consultations. RNs who have advanced skills in this field run early childhood clinics. Specialist early childhood nurses are supported by paediatricians and other allied health professionals.
Early childhood services, which began over 70 years ago, largely provide preventive healthcare to mothers and babies, with an emphasis on education. This service gives appropriate support to mothers, newborn babies and young children until they go to school. Early childhood nurses visit mothers at home and arrange mother and baby clinics for particular language groups, for example Chinese or Vietnamese. Group work is offered to mothers who may benefit from meeting other mothers, and special support is offered to single mothers.
School health services do not simply offer first aid and symptom management to children who get ill at school. In fact, effective school health services are comprehensive programs that integrate health education principles throughout a school’s curriculum. They protect and promote the health of all students and school personnel. School health nurses are specialised in school nursing practice. This service is beginning to see a resurgence, having been somewhat dismantled over the past two decades.
Occupational health and safety in the work setting has gained importance as employers have sought to reduce the costs of health insurance benefits for injured or ill workers. Occupational health is a national concern, affecting individuals, families and communities. A comprehensive occupational health program geared to health promotion and accident or illness prevention can increase worker productivity, decrease absenteeism, reduce use of expensive medical care, and lower disability claims.
Occupational health nurses conduct environmental surveillance (hazardous equipment, injuries occurring in the workplace, potential stressors) and are involved in nursing care delivery (physical assessment, screening, emergencies), health education, communicable disease control, counselling, administration and research. Recurring issues that nurses face in the workplace are manual handling issues, needle-stick injury, concerns related to infectious diseases and exposure to environmental hazards. One of the nurse’s roles is to help ensure that workers who have been injured have recovered sufficiently to return to the work site safely. Most healthcare facilities try to reintroduce employees into the workforce as soon as possible after illness or injury, even if they assume a different job temporarily. The nurse can enhance the work experience by devising programs that involve workers in creating a safe work environment.
Primary-level care focuses on personal health services, for example NP or GP roles. The primary healthcare model focuses on collaboration of healthcare professionals, community members and others working in multiple sectors, emphasising health promotion, development of health policies, and prevention of diseases. For example, the health problems that commonly affect members of a lower socioeconomic group can often be traced to poor community services, for example water treatment, waste disposal, air quality or transport services.
Successful health promotion programs are designed to help people acquire healthier lifestyles and achieve a decent standard of living. Health promotion programs can lower the overall costs of healthcare by reducing the incidence of disease, minimising complications and thus reducing the need to use more expensive healthcare resources. Preventive care is more disease-oriented and focuses on reducing and controlling risk factors for disease through activities such as immunisation and occupational health programs. Health promotion is a major theme within primary and preventive care settings.
Māori health services in New Zealand have been developed by individual iwi (tribal groups) to encourage better uptake of primary healthcare services through the provision of services that are culturally appropriate. The high number of people from Pacific countries in some parts of New Zealand has also resulted in the development of Pasifika health services or clinics, particularly in the North Island. These services also play an important role on health promotion, especially where particular diseases (e.g. type 2 diabetes) are more prevalent among particular ethnic or cultural groups.
Australia and New Zealand are multicultural societies comprising a large number of people from different nationalities. Many do not have English as their first language, and some may suffer from particular diseases (e.g. tuberculosis) which have previously been controlled within the country’s population. This is of particular note within refugee groups.
The challenge for all healthcare professionals is to understand the health needs of different cultural groups in order to provide appropriate services. The concept of cultural safety in nursing will be discussed in later chapters.
Hospitals fit into two categories: public and private. It is possible to be a private client in a public hospital but not a public patient in a private hospital, as the ‘private’ classification refers only to mechanisms of payment and choice of doctor. Hospital emergency departments, critical care and inpatient medical–surgical units are the sites where secondary and tertiary levels of care are provided. In these settings, nurses work closely with all members of the healthcare team to plan, coordinate and deliver care for people who are seriously ill.
Nurses must constantly monitor and evaluate whether care is effective and how it can be improved. Acute care nurses respond to clients’ needs and expectations to form effective care partnerships. With the arrival of case-mix and the associated diagnosis-related groups (DRGs) (Palmer and Short, 2010), clinical pathways and case management, the expectation is that a hospitalised client with a given medical diagnosis or who undergoes surgery will be cared for and discharged within a projected time period. This forms the basis for the activity-based funding model spoken of earlier in relation to government funding. Emphasis is on efficiency and appropriate use of resources necessary to adequately care for the client until discharge. Case management is one approach to coordinating a client’s care throughout the hospital stay and after discharge. The multidisciplinary team approach maximises the opportunity for the client to have a well-designed discharge plan.
In Australia, short-stay and day-only wards allow for greater efficiency and effectiveness for people who require diagnostic and short-length-of-stay treatments. The proportion of surgical day-only cases is rapidly increasing, which leads to changing nursing roles both in the perioperative area and in the community. The majority of elective surgery is now undertaken in private hospitals, with much of it day-only or short-stay.
Hospitalised clients are often very ill and in need of comprehensive and specialised tertiary healthcare. Perhaps one of the biggest influences on hospital nursing is patient acuity, which relates to the client’s level of illness and the total time required to care for the client over a 24-hour period. For example, a major neurosurgical procedure may require 16 hours of postoperative nursing care in 24 hours in an intensive-care unit, whereas a client having a hysterectomy may require 4 hours of postoperative nursing care over a 24-hour period.
Clients may still be relatively ill when discharged from hospital and, as a result, nurses rarely see clients who have gained complete symptom relief or who do not require some level of intense intervention. The care of hospitalised clients requires nurses to have knowledge and skills related to clinical problem solving and critical thinking. Care provision also requires nurses to have contact with clients on an ongoing basis so they can recognise changes in their clinical condition. When working with nursing assistants, it is important for nurses to recognise that their priority is client assessment and clinical decision making.
The services provided by hospitals can vary considerably. Small rural hospitals may offer limited emergency and diagnostic services as well as general inpatient and aged-care services, whereas large urban medical centres usually offer comprehensive, state-of-the-art diagnostic services, trauma and emergency care, surgical intervention, intensive-care units, inpatient services and rehabilitation facilities. Larger hospitals also offer professional staff from a variety of specialties, such as social workers, physiotherapists, occupational therapists, podiatrists and speech therapists. The focus in hospitals is to provide the highest quality of care possible so that clients can be discharged early but safely to their home or to a facility that can adequately manage their remaining healthcare needs.
In hospital settings, nurses have opportunities to work in a variety of roles and in different departments. RNs provide comprehensive nursing and medical therapies, educate clients and families, facilitate family support and coordinate healthcare services and discharge planning. As the depth of nursing knowledge increases, many nurses specialise in their practice. This allows them to become expert in the care of select client populations, for example in oncology or cardiothoracic nursing. Other opportunities may include the roles of patient representative, nurse manager, clinical nurse specialist, clinical educator, clinical nurse consultant, NP or infection control coordinator.
A critical-care or intensive-care unit (ICU) is a hospital unit in which clients receive close monitoring and intensive medical care. The units are equipped with the most advanced technologies, such as computerised cardiac monitors, mechanical ventilators and blood perfusion devices. Although many of these devices can be found in regular nursing units, the clients hospitalised within ICUs are monitored and maintained on multiple devices at the same time. Nursing and medical staff in an ICU are educated in critical-care principles and techniques. It is the most expensive delivery site for medical care because of the medical and nursing staffing patterns required to deliver care via the related volume of treatments and procedures the clients must undergo.
High-dependency units are designated sites within hospitals that provide medical and nursing specialty care for clients who need a greater intensity of care than is generally provided in a skilled nursing unit/ward, but who no longer require intensive care. Generally, clients who have undergone major surgery or have suffered injury or worsening of a chronic disease and require continued hospitalisation are candidates for high-dependency care. Typical clients include those who have experienced cerebrovascular accidents, major surgery trauma or respiratory failure. Such clients require a transitional phase of stabilisation and often still have intensive medical, social and familial needs. Many of the clients who require high-dependency care are from other medical or surgical wards.
People who suffer mental, emotional and behavioural problems such as depression, behavioural disorders and eating disorders often require special counselling and treatment in psychiatric facilities. Located in hospitals, independent outpatient clinics, private mental health hospitals and community health centres, psychiatric facilities offer inpatient and outpatient services, depending on the seriousness of the problem. Clients may enter these facilities voluntarily or involuntarily. Hospitalisation involves relatively short stays for stabilising clients, followed by transfer to community treatment centres. In New Zealand, ongoing residential care is usually provided by a range of NGOs or through community mental health teams providing care for service users in their own home.
A comprehensive multidisciplinary treatment plan involving clients and families is established for clients with mental illness. Medicine, nursing, social work and other professionals collaborate to develop a plan of care that will enable clients to return to functional states within the community. At the time of discharge from inpatient facilities, clients are usually referred to follow-up care with counsellors, doctors, mental health nurses or other mental health professionals, usually within community teams. Private clients often have access to private psychiatrists, psychologists and mental health NPs.
Pastoral care services are a key element in healthcare services for both clients and staff, and are widely used by healthcare teams. All large and moderately sized hospitals have a formal pastoral care service, whereas smaller hospitals and other healthcare facilities have a more informal arrangement, usually with local clergy.
Pastoral care services are always interdenominational and often include religions other than the various Christian denominations. Educational programs are available for clergy and laypersons and include continuing education, certificate courses and degrees. The healthcare system in Australia recognises the importance of pastoral care services as part of the healthcare required by clients.
Clinics assess and treat clients on an outpatient basis. A clinic may be affiliated with a public hospital, community services, early childhood services, mental health services or drug and alcohol services. Most clinics are within public hospitals. The nature of the clinic affiliation often determines the type of services a clinic provides. For example, hospital clinics offer diagnostic and treatment services. A clinic in the community may offer primary care such as immunisations, screening services (e.g. breast screening by mammogram), women’s health services or tuberculosis treatment. In Australia it is not uncommon to have mobile screening vehicles that go to various rural areas and to various suburban shopping centres. There are also clinics that offer comprehensive care to specific client populations, for example allergy and well-baby clinics.
Specialist medical officers, community services, emergency departments, GPs and NPs usually refer clients to clinics after discharge as inpatients. Community health nurses play an important role in planning and providing clinic healthcare services. A comprehensive assessment of community needs is critical to ensure that clinic programs cover the health status, lifestyle patterns and cultural diversity of its clients. Often a neighbourhood clinic becomes a focal point for a community. The successful clinic recognises the work and lifestyle patterns of its clients and establishes a strong network of relationships with places of worship, schools and businesses. The networks often become important in continuing care after people leave hospital.
Hospital-in-the-home (or post-acute-care services) is a concept that has developed over the last two decades, largely as a mechanism to reduce the length of stay in hospitals for some people, for example burns patients, respiratory patients and wound-care patients.
Some hospitals have introduced a hospital-in-the-home concept for their ambulatory services, for example emergency department. Hospital-in-the-home care is a synthesis of community health nursing and selected specialised clinical skills from other nursing specialties, for example burns unit, where care once given in hospital is provided in the client’s home.
Rehabilitation is the restoration of a person to optimal physical, mental and social health with optimal ability for meaningful work. People require rehabilitation after a physical or mental illness, injury or drug and/or alcohol addiction. Rehabilitation was once available mainly for people with illnesses or injury to the nervous and/or musculoskeletal systems, but the healthcare system has expanded its scope of such services. Today, specialised rehabilitation services, such as cardiovascular and pulmonary rehabilitation programs, help clients and families adjust to necessary changes in lifestyle and learn to function with the limitations of their disease. Drug rehabilitation centres help the client become free from drug dependence and return to the community.
Rehabilitation services include physical, occupational and speech therapy (see section on allied health services, below). Ideally, rehabilitation begins the moment a person enters a healthcare setting for treatment; for example, some orthopaedic programs now have clients undergo a physical therapy exercise before major joint repair to enhance their recovery postoperatively. Initially, rehabilitation may focus on preventing complications related to the illness or injury. As the condition stabilises, rehabilitation is directed at maximising the person’s functioning and level of independence.
Rehabilitation occurs in many healthcare settings, including rehabilitation institutions, outpatient settings and the home. Frequently, people needing long-term rehabilitation (e.g. stroke and spinal injury clients) have severe disabilities affecting their ability to carry out activities of daily living. When rehabilitation services are provided in outpatient settings, clients receive treatment at specified times during the week, but remain at home the rest of the time. Specific rehabilitation strategies are applied to the home environment so that maximal levels of function and independence can be achieved.
As indicated earlier in this chapter, rural and remote health in Australia suffers particularly from a shortage of doctors, specialist nurses and midwives. Because Australia has a sparse population in most of its landmass, some small country towns have seen their small hospital, which has cared for elderly residents under a nursing-home-bed classification, close their doors. These small hospitals also managed acute care and emergency patients until they were stable enough to move to a base hospital. Like many countries, Australia must deal with issues related to having appropriate healthcare facilities given the finite nature of healthcare resources.
With healthcare reform, there is an increase in the number of city hospitals branching out and establishing affiliations with rural hospitals. The rural hospitals provide a referral base to the larger tertiary-care medical centres. This networking or linking of rural and metropolitan hospitals should improve the quality of rural healthcare provision.
Some large tertiary-care healthcare organisations have extended their services to include exchanging personnel, such as midwives, to help with shortages at rural hospitals. Many midwifery and nursing programs encourage students to experience a rural situation within the course, and rural undergraduate student nurses and midwives often undertake an elective of study within a city hospital or community health service. These types of exchanges allow a greater degree of understanding to take place about both rural and city health delivery.
While New Zealand is not faced with the same issues of remoteness as Australia, isolated rural communities continue to face challenges in accessing effective healthcare, and are particularly challenged by the closure of small hospitals or clinics. Some communities have been able to establish new service bases using the services of visiting healthcare professionals.
Physiotherapy relates to therapeutic exercise, gait training, use of walking aids, massage, application of heat and cold to joints and muscles, hydrotherapy and electric stimulation of nerves. Physiotherapy is practised within public and private hospitals, nursing homes, community health services and in private practices. Physiotherapists are important providers of healthcare within the healthcare system and can work in independent practice or as a member of a multidisciplinary team.
Treatment through purposeful activity for people whose ability to perform activities of daily living is impaired include:
Treatments and counselling in the prevention or correction of speech and language disorders include measuring and evaluating language abilities, auditory processes and speech production, and clinical treatment of clients with speech and language disorders.
Aged-care facilities have been prominent and growing within Australasia for several decades. As in other Western countries, the Australasian population continues to age, largely because people are living longer as a result of advanced medical techniques, treatments and support services and a greater emphasis on healthier lifestyles. Many ageing people are able to remain in their own home longer or until their life ends. Some, however, require care in nursing homes, hostel accommodation or self-care accommodation within aged-care facilities. Each of these environments, however, still has implications for nursing practice (see Box 2-3). Nursing homes can be stand-alone facilities or part of a retirement village. Hostel accommodation can be part of a nursing-home complex or a retirement village. A retirement village is often a complex made up of a nursing home, hostel accommodation and self-care accommodation. Nursing homes provide 24-hour care for the aged, chronically ill and disabled. Hostel accommodation within an aged-care facility provides an independent facility for living, for example bedroom, ensuite and lounge, with meals and other common services being provided. Self-care accommodation within an aged-care facility allows the person to be totally independent. Hostel accommodation in Australia may have services which include meals, social and recreational programs, personal laundry, housekeeping, transportation, an emergency call system and health checks. With the ageing of the population, greater attention has been paid to aged-care facility planning and funding, and many schemes are funded as government priorities to attract RNs into aged care.
BOX 2-3 NURSING FUNCTIONS IN CARING FOR OLDER ADULTS IN INSTITUTIONS
• Provide a milieu for living rather than for illness and dying.
• Learn about and use community resources; advise family and clients of same.
• Establish short-term and long-term goals; periodically evaluate progress towards both.
• Secure and maintain health, recreation and social history.
• Communicate clients’ needs in written and verbal form.
• Give treatments, medications and rehabilitative exercises.
• Observe and evaluate client response to treatment, medications and care plan.
• Teach healthcare maintenance to staff and clients.
• Keep doctor aware of changes in clients’ condition.
• Institute life-saving measures in the absence of a doctor.
• Perform physical assessment of clients.
• Ensure adequate medical, dental and podiatric care for clients.
• Support clients in achieving highest level of autonomy possible in the situation.
• Provide appropriate information to clients and family about treatment plan, medications and diagnosis in collaboration with doctor.
• Collaborate with other professionals, clients and family to develop a comprehensive care plan.
• Supervise ancillary personnel.
• Recognise implications of syndromes for client care (e.g. renal failure, coronary disease, emphysema).
• Protect clients from injury or iatrogenic disease.
• Perform physical and psychosocial assessments and integrate in nursing care plan.
• Initiate action as outlined in nursing protocols regarding various conditions.
• Provide emergency treatment as needed (e.g. cardiopulmonary resuscitation, treating shock, haemorrhage, convulsions, poisoning).
• Alert doctor to changes in client status and abnormal findings of tests.
The need to care for family members within the home creates great physical and emotional burden for adult caregivers. The caregiver is usually an adult who not only has the responsibility for providing care to a loved one (e.g. spouse, parent or sibling), but often must maintain a full-time job and manage the routines of daily living. Respite care is a service that provides short-term relief or time off for people providing home care to the ill or disabled (e.g. children, psychiatric clients or frail older adults). Adult day-care is one form of respite care, but healthcare professionals and trained volunteers can also provide respite care within the home. The caregiver is able to leave the home for errands or for some social time, while a responsible person stays in the home to care for the loved one.
A hospice is a unit within a hospital or can be a designated hospital in itself for clients who have reached the terminal phase of an illness. The focus of a hospice is palliative care, not curative treatments. A hospice can benefit a client in the terminal phases of any disease, such as cardiomyopathy, multiple sclerosis and cancer. Usually the client, family and doctor have agreed that no further treatment could reverse the disease process. The client and family must understand that the hospice will not use emergency measures such as cardiopulmonary resuscitation to prolong life. Instead, the hospice uses a multidisciplinary approach to provide pain control and comfort measures and death with dignity.
Hospice nurses work in institutional and community settings. They are committed to the philosophy and objectives of the facilities for which they work. They provide care and support for the client and family during the terminal phase, at the time of death, and continue to offer bereavement counselling to the family after the client’s death. Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family. Hospices in New Zealand are not funded through central government.
Mrs Jackson is a 52-year-old woman who was employed as a faculty member at a major university. She was in a car accident 1 week ago, suffering a fractured leg and bruised ribs. She hopes to return to work before the semester is over. Her nursing care needs have involved mainly pain management, good skin care and physiotherapy. She will continue to have stability aids and have difficulty with mobility for many weeks.
What level of healthcare will Mrs Jackson require before returning to work?
Healthcare quality and safety are increasingly important international areas of study, as concern has arisen about client safety within healthcare systems. The Institute of Medicine in 1999 with the landmark report To err is human: building a safer health system was pivotal in highlighting the unacceptable nature of accidents and adverse incidents in hospital, and there has been a growing body of research into this area since then. The Institute of Medicine’s website (see Online resources) continues to offer excellent quality and safety resources. In Australia the federal government in mid 2011 set up the Australian Commission on Safety and Quality in Health Care. This permanent Commission is to lead and coordinate improvements in safety and quality in healthcare across Australia; the website (see Online resources) contains up-to-date information in this area.
The marked change in thinking about quality and safety is the move from the idea of blaming the individual clinician if something goes wrong to looking for system errors that have contributed to the accident or problem. It is an extremely positive move, both in protecting clinicians from being scapegoats for broader systemic problems and in enhancing the chances that the same mistakes will not happen again. Institutions each have mechanisms of handling medical errors and incidents and in investigating their occurrence and the systems changes that may prevent their recurrence. In New Zealand, the Health and Disability Commissioner (see Online resources) appointed by the government is responsible for this role.
This discussion of the healthcare delivery system began with the issue of change. Change often creates chaos, but it also creates opportunities to improve the way things are done. The primary focus in designing and delivering healthcare is the health and welfare of the population. Healthcare in Australia and New Zealand has not yet created a seamless continuum of services; however, many healthcare organisations are striving to find ways to redesign their services, contain costs, improve access to services and guarantee high-quality client care. Nursing is an essential contributor to the future of healthcare delivery.
Duckett’s The Australian health care system (2007:308–9) ends with a description of what an ideal healthcare system would look like:
• First, it would start with strategies to assist the consumer to make informed choices. [Call centres providing evidence-based protocols] providing health advice and advice about sources of care including costs, waiting times and quality.
• Second, [it would be] based on locally accessible multidisciplinary health teams. Such teams would include general practitioners, nurses, pharmacists, physiotherapists, and so on. The teams would have links to locally based specialists. In rural areas especially, the teams would include a number of nurse with the right to prescribe commonly needed medications (nurse practitioners), to ensure accessible primary care.
• Third, there needs to be a network of hospitals and day procedure centres, even though they are the most expensive part of any health care system.
The ideal system would need to be supported by a sophisticated information technology infrastructure, facilitating transmission of information between the various providers of care, when authorised by the patient.
Funding of this system would be on an equitable basis, through general taxation. Individual providers should have incentives for efficiency: hospitals should be funded on a case-mix basis; primary care teams on a mix of activity (fee for service) and program payments
Specifying ideal systems is relatively easy. The difficult task is managing the transition from the current system to this nirvana.
Nurses have a key role to play in moving to such an improved system. Fundamental to such an active role is information and a developing understanding of what the healthcare system is and how it works. The latest round of health reforms positions us closer to this ideal. The challenge is to reach it.
KEY CONCEPTS
• Funding healthcare under current arrangements cannot depend on Medicare alone, but requires consumers to take out private health cover or understand the need to pay the gap in cost.
• Levels of care describe the scope of services and settings where healthcare is offered to clients at all stages of health and illness.
• Community health services cover a wide span of healthcare, from acute postoperative care to aged care.
• Primary healthcare looks beyond personal healthcare services and focuses instead on determinants of health for a population.
• Although hospitalised clients are acutely ill, there is an emphasis on efficient use of resources and timely discharge.
• The intensity of care has increased in community services because of earlier hospital discharges.
• The emphasis on quality improvement within healthcare leads to improved standards of care.
• The professional nurse is accountable for remaining competent within the rapidly changing healthcare environment.
• The nurse can influence client satisfaction by understanding a client’s expectations and by giving compassionate care.
Aboriginal and Torres Strait Islander Health Performance Framework, 2010 Report; the framework monitors Indigenous Australian health outcomes, health system performance and broader determinants of health, www.health.gov.au/indigenous-hpf
Australian Commission on Safety and Quality in Health Care, www.safetyandquality.gov.au/
Health and Disability Commissioner, www.hdc.org.nz
Institute of Medicine, www.iom.edu
The future of nursing: leading change, advancing health; outlines the vital role that nurses can play in helping realise the objectives set forth in the 2010 Affordable Care Act, www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
To err is human: building a safer health system; outlines the comprehensive strategy by which government, healthcare providers, industry and consumers can reduce preventable medical errors, www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx
National Health and Hospitals Reform Commission, final report June 2009; outlines the development of the long-term health reform plan for a modern Australia, www.health.gov.au/internet/nhhrc/publishing.nsf/Content/home-1
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