Chris Ham (chief executive of the King’s Fund.) in the BMJ 30th November: Chris Ham: Learning from others—devolved governance in the Australian state of Victoria
Community Mental Health is not mentioned by Chris Ham, but Mark Britnell applauds their attempts to keep patients in the community. Australia may not be the perfect system, but it is attracting many British trained doctors right now, and has a greater proportion of private funding in the GDP spend. If the system is not built on sand, and is sustainable, doctors will support it. Devolution (post code lottery) in the UK has always been present between states in Aus.. but they are allowed co-payments, insurance top ups and discourage dependency…
I spent a week working in Australia earlier this month and it made me reflect on similarities and differences with the NHS in England.
The funding context feels quite different, with healthcare spending in Australia having risen by 5% per year in real terms over the past decade. On the day I departed, a report in The Australian warned that this level of spending increase was unsustainable at a time of reduced economic growth and falling government revenues (the Chinese downturn being a key factor here). A summit organised by the Business Council of Australia discussed various options for reform, including moving away from fee for service payments for doctors, empowering consumers, making better use of technology, and achieving greater coordination of care.
Reform in Australia is being debated in a context that is much more complex than in England. Not only is responsibility for healthcare split between the commonwealth and state governments, but also the private sector plays a much bigger part in the funding and provision of care. Divided responsibilities in government and the public–private mix create obvious challenges in migrating towards the integrated care models seen by many as holding the key to delivering better value for the population.
Another big difference is that devolution is a concept in England, but a reality in Australia where state governments enjoy considerable discretion in deciding how to organise the health services for which they have responsibility. The result can be seen in variations in the degree of delegated decision making within states and in how services are funded and managed. Devolution is accompanied by healthy competition between states to demonstrate innovations in organisation and care delivery and superior performance for their populations.
My visit was prompted in part by work the King’s Fund has been commissioned to do by the health department in the state of Victoria, involving an independent assessment of the state’s model of devolved governance in healthcare, which is similar in some respects to the “earned autonomy” regime used in England in the 2000s. Nick Timmins and I have spent the past few months interviewing key stakeholders, analysing documentary evidence, and using available data to understand health service performance in the state and how it compares with the rest of Australia.
Our analysis shows that Victoria delivers good results in comparison with other parts of Australia, being on, close to, and sometimes above the average on many indicators. Underpinning Victoria’s performance is a well understood governance model that gives the boards running health services at a local level considerable autonomy within a state-wide framework of priorities.
Also important has been a high degree of organisational stability (unusual and enviable from an English perspective), continuity among senior leaders, and the pioneering use of case-mix funding that has contributed to the costs of care being lower than in other states. Devolved governance has contributed to a number of innovations in care, including the Hospital in the Home programme that on a typical day is responsible for around 550 patients who might otherwise be occupying a hospital bed.
Recognising these achievements, our report concludes that there are several areas where Victoria could make improvements. These include reviewing the number of boards—there are more than 80 for a population of around 6 million—and bringing greater independence into the appointment of board members to ensure they are selected on the basis of skills and experience.
There is also a compelling case for greater collaboration between boards. This is particularly important in the case of boards responsible for regional and rural health services, where isolation from other health services creates risks in relation to the safety and quality of patient care—as illustrated by recent failures of perinatal care at Djerriwarrh Health Service, where a recent report found seven of the 10 stillbirths and neonatal deaths that occurred there in 2013 and 2014 could have been avoided.
The transparent reporting of data on performance could help to avoid failures like this in future. Not only would transparency strengthen accountability to the public, but it would also support healthcare providers to compare their performance with others and identify areas in which they can improve. New South Wales does this through its Bureau of Health Information and I met with the Bureau’s staff in Sydney to learn about their work in that state.
At a time of huge and growing challenges in the NHS, we should look to other healthcare systems, share learning with each other, and borrow the best ideas.
Chris Ham is the chief executive of the King’s Fund.
and in the BMJ 27th November 2015: Richard Smith: The NHS—a terrible thought
There is great reluctance in Britain to consider any other kind of funding for the NHS apart from taxation, but we are surely close to a time when we will have to consider it. This morning I awoke with the thought, which felt terrible, that funding through taxation is a straitjacket that is causing increasing pain.
It’s effectively a law of economics and health that as countries get richer they spend more money on healthcare. And we know that at least some (probably many) people are willing to pay substantial sums for a few months, weeks, or even days of life. Indeed, as economists point out rational people who assume that their wealth will have no value to them once they are dead might rationally spend all their wealth on extra life: the “opportunity cost” is close to zero…..