Search

This paper explores whether middle-income Asian countries are reorienting their health services in response to non-communicable diseases (NCDs). Malaysia, Sri Lanka, and Thailand were selected as case studies of Asian societies experiencing rapid increases both in NCDs and an aging population. While NCD programs, especially those related to diabetes and stroke, are well-established in Thailand, health services struggle to respond to increasing numbers of people with chronic health problems. Health services at all levels must plan ahead for more patients with chronic and often multiple conditions who require better integrated health care.

Objective To explore the applicability of a patient complaint taxonomy to data on serious complaint cases. Design Qualitative descriptive study. Setting Complaints made to the New South Wales (NSW) Health Care Complaints Commission, Australia between 2005 and 2010. Participants All 138 cases of serious complaints by patients about public hospitals and other health facilities investigated in the 5-year period. Main Outcome Measure A thematic analysis of the complaints was conducted to identify particular complaint issues and the Reader et al. (Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014;23:678–89.) patient complaint taxonomy was then used to classify these issues into categories and sub-categories. Results The 138 investigated cases revealed 223 complaint issues. Complaint issues were distributed into the three domains of the patient complaint taxonomy: clinical, management and relationships. Complaint issue most commonly related to delayed diagnosis, misdiagnosis, medication errors, inadequate examinations, inadequate/nil treatment and quality of care including nursing care. Conclusions The types of complaints from patients about their healthcare investigated by the NSW Commission were similar to those received by other patient complaint entities in Australia and worldwide. The application of a standard taxonomy to large numbers of complaints cases from different sources would enable the creation of aggregated data. Such data would have better statistical capacity to identify common safety and quality healthcare problems and so point to important areas for improvement. Some conceptual challenges in devising and using a taxonomy must be addressed, such as inherent problems in ensuring coding consistency, and giving greater weight to patient concerns about their treatment.

Objective. To analyse the strategies used by hospital leaders to improve compliance with the ‘ensuring correct patient, correct site and correct procedure protocol’. While following such a protocol saves lives according to an international study of the World Health Organization safe surgery checklist, promoting compliance in hospitals has proved to be a regulatory challenge. Design, Setting and Participants. Using a qualitative research design and ‘responsive regulation’ theory, this study explored implementation strategies used by hospital leaders in 20 Australian public hospitals. Semi-structured interviews were conducted with 72 informants to analyse how front-line leaders improved compliance with the safe surgery protocol in their hospitals. Interventions. Implementation analysis of the safe surgery protocol. Main Outcome Measures. The use of implementation strategies located on a ‘responsive regulation’ pyramid. Results. Informants identified many strategies used to improve protocol compliance typically beginning with persuasion. Supportive strategies were located on a regulatory pyramid beginning with softer interventions: persuade, enlist leaders, train, remind, relax protocol requirements, redesign hospital systems and reward compliance. In response to low and slow compliance, many hospital leaders switched to a pyramid of escalating sanctions: direct, delegate, monitor, publicly report, reprimand and penalize. Conclusions. A multiplex problem requires graduated and multiplex regulation. Hospital leaders proved to be responsive regulators in applying both multiple supports and sanctions that improved compliance over 3 years. These experiences with protocol implementation illustrate the multifaceted challenge of health sector regulation and offer lessons for embedding future patient safety solutions.

Aim: To describe the Dynamic Analyses to Optimise Ageing (DYNOPTA) project and illustrate its contributions to understanding ageing through innovative methodology, and investigations on outcomes based on the project themes. DYNOPTA provides a platform and technical expertise that may be used to combine other national and international datasets. Methods: The DYNOPTA project has pooled and harmonised data from nine Australian longitudinal studies to create the largest available longitudinal dataset (n= 50652) on ageing in Australia. Results: A range of findings have resulted from the study to date, including methodological advances, prevalence rates of disease and disability, and mapping trajectories of ageing with and without increasing morbidity. DYNOPTA also forms the basis of a microsimulation model that will provide projections of future costs of disease and disability for the baby boomer cohort. Conclusion: DYNOPTA contributes significantly to the Australian evidence base on ageing to inform key social and health policy domains.

Objective This paper explores how hospital complaints managers react to recommendations for systemic quality reforms by health complaints commissions in response to complaints by patients in Queensland and New South Wales. Methods Semi-structured qualitative interviews were conducted with complaints managers in 17 hospitals. Interview transcripts were then thematically analysed and data on responses to health complaint commissions was organised in relation to Valerie Braithwaite’s typology of motivational postures. Results Respondents supported involvement by an independent authority where patients had serious complaints about the services they received in hospital, but wanted more negotiation with commissions on service improvement recommendations. Conclusions Hospital complaints managers mostly responded as virtuous or rational actors to the symbolic power of complaints commissions. This may be context dependent because Australian health commissions operate within a pro-reform context as a result of recent publicity around health system failures. What is known about the topic? Little is known about regulatory relationships between complaints commissions and hospitals. There has been no Australian research considering how complaints managers respond to commission recommendations for quality improvements and reforms to hospital services. What does the paper add? The paper uses a novel theoretical framework based on regulatory theory to understand and describe the reactions of complaints managers to commission recommendations. What are the implications for practitioners? Commissions should seek commentary from complaints managers through open dialogue before making final recommendations. This will ease the progress of reforms and make recommendations more acceptable and ‘genuine’ in the specific context of the hospital.

The United Kingdom, faced with a legacy of long-term under investment, has embarked on a major programme of hospital development. This raises many questions. What factors influence the work of the hospital? How can hospitals continue to adapt to changing circumstances? This paper draws on a recent study of the role of the hospital in Europe. It identifies major gaps in information about what hospitals do and how they are changing. International comparisons are especially difficult because of differences in definitions. The challenges that hospitals face can be categorised under three broad headings: the health needs of the population; opportunities and constraints they face in providing care; and the consequences of wider societal and economic factors that shape their environment. Health needs reflect the composition of the population (births, ageing, and migration), changes in risk factors, and changes in public expectations. Hospitals gain opportunities, but also face constraints as a result of changes in the workforce on which they draw and the technology that is available to them. They must also work within the constraints imposed by wider societal developments, such as the economy. Hospitals must also take account of their role as centres of teaching and research, as well as their responsibilities to the local community. Hospitals across Europe have changed considerably in the 1990s, with more people being admitted but staying for shorter periods. With the additional demands created by growing rates of day care and outpatients, hospitals are currently much busier places than in the past. There have also been considerable reconfigurations of hospitals in many countries. Some have been more successful in implementing change than others. Successful change is more likely where a whole system approach to health care is taken. Granting managerial autonomy to individual hospitals makes change less likely. Planning approaches are more successful than market-based ones. Change often requires construction of new facilities. The increasingly rapid pace of change in health care means that hospitals will have to adapt much more quickly than in the past. This will require a long-term programme of sustained and stable investment.

Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.

Self-medication among the study respondents ranged from 18% to 36% between 1992 and 2004. The most frequent classes of complementary and alternative medicines were vitamins and minerals, herbal medicines and nutritional supplements, with younger individuals and women more likely to use them. For over-the-counter (OTC) medicines, the most commonly used were analgesics, laxatives and low-dose aspirin. Use of OTC medicines seemed to be done in accord with indications officially approved by the Australian medicine agency. Future work should examine risks associated with the concomitant use of complementary and alternative medicines, prescription and OTC medicines., National Health and Medical Research Council (410215); NHMRC Fellowships (#366756 to K.J.A. and #316970 to P.B.)

Hospital elderly care teams in England assess whether patients need assistance, such as community or residential care, upon discharge from hospital. Does the type of multidisciplinary team influence post-hospital care decisions? The aim of this study was to identify which factors predict the services that older people receive upon discharge from hospital. Three multidisciplinary teams were compared where different professionals took the lead in co-ordinating the care assessment process. Data were collected in a case note review of patients (n = 456) aged 75 years and over: patient characteristics, referral patterns, and the types of service received in the month after leaving hospital. Multivariate statistical analysis (controlling for patient characteristics) showed different predictors for different post-hospital services. The nurse-led team was least likely to refer patients for care assessment and these patients received the least post-hospital services. The occupational therapy-led team arranged the most occupational therapy services and equipment and their patients received the most home care. The social work-led team referred the most patients for care assessment and their patients received the greatest range but not the greatest amount of services. These results suggest that multidisciplinary team configurations influence post-hospital services for older patients, reflecting professional preoccupations as much as patient care needs.

The success or failure of health sector reform in the countries of Central and Eastern Europe depends, to a large extent, on their health care staff. Commentators have focused on the structures to be put in place, such as mechanisms of financing or changes in ownership of facilities, but less attention has been paid to the role and status of the different groups working in health care services. This paper draws on a study of trends in staffing and working conditions throughout the region. It identifies several key issues including the traditionally lower status and pay of health sector workers compared to the West, the credibility crisis of trade unions, and the under-developed roles of professional associations. In order to implement health sector reforms and to address the deteriorating health status of the population, the health sector workforce has to be restructured and training programmes reoriented towards primary care. Finally, the paper identifies emerging issues such as the erosion of 'workplace welfare' and its adverse effects upon a predominantly female health care workforce.

Despite different delivery systems for home care, similar services were delivered to similar proportions of elderly people in Sydney, Melbourne and Adelaide in 1981. Per capita government expenditure on home care in the three States varied, as did the cost of service delivery. Client characteristics also differed, in that the health-oriented regional services in Adelaide had more disabled and more poor clients, while local government in Melbourne and local voluntary groups in Sydney served a more mainstream clientele. Substantially more funds have gone to home care through the HACC Program, warranting an analysis of current service patterns, client characteristics and client outcomes.

SynopsisMost family research on “who does the housework” focuses upon couples with dependent children. This study analyses data from the Australian National University survey of elderly people living at home. Most retired couples manage without outside assistance and maintain very traditional gender roles. However, task responsibilities between couples shift with disability, and to a lesser extent with ageing. The wife’s prior workforce participation is associated with a more flexible division of household responsibility, and ethnicity with a lessflexible division. The ability of the husband or wife to take over tasks in the event of the incapacity or loss of a partner has important consequences for their quality of life and independence, and for community care policies.

• The first aim of a medical registration scheme should be to protect patients. • Medical registration boards currently offer variable information to the public on doctors' registration status. • Current reform proposals for a national registration scheme should include free public access to professional profiles of registered medical practitioners. • Practitioner profiles should include: > practitioner's full name and practice address; > type of qualifications; > year first registered, and duration and type of registration; > any conditions on registration and practice; > any disciplinary action taken; and > participation in continuing professional education.

This commentary paper argues that the Asia‐Pacific region would benefit from a home‐grown version of the European Observatory on Health Care Systems to inform health sector policy: an Asia‐Pacific Observatory. The countries in this diverse region, ranging from highly developed to very poor countries, are undergoing dramatic and diverse health sector changes, often on the basis of little evidence and with little information on successes and failures in neighbouring countries. The inter national community also is interested in knowing more about the many distinctive models of Asia‐Pacific health care. While statistical comparisons are important, health policymakers and researchers need to understand the story behind the statistics in order to interpret the numbers and to formulate policies and strategies. Health system profiles therefore are useful instruments that describe how a complex health sector works, offer a comparative framework for cross‐national comparisons, identify trends in health system design, and with standardised measures and regular updates measure progress against benchmarks. These reports and expanded analyses have influenced both national and Europe‐wide debates on health policy. In the Asia‐Pacific region, health systems research has built up a critical mass of studies and people with strong links across countries. The next ambitious steps are to identify sponsors able to support an enterprise that transcends national boundaries and to begin a project of comparative studies of national health systems.