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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.

Health ombudsmen (health complaints commissioners), an unusual entity internationally, exist only in England, New Zealand, and the Australian states and territories. Established to respond to complaints from patients, the intention is to make health services and professionals more accountable to the public. Most cases are handled around the softer base of a regulatory pyramid, such as advice to complainants and requests to providers for an explanation and/or apology. Few cases escalate to investigations and prosecutions. Although the legal powers of some health ombudsmen to redress individual grievances have been strengthened, most lack the independent power to initiate an inquiry into systemic problems. To produce quality improvements, health ombudsmen need powers to require compliance from providers and to initiate inquiries. With the advent of new health sector regulators, health ombudsmen must negotiate their role and function within expanding networks of governance.

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.

This study is concerned with "standards of quality and safety" within health and social care systems. Care standards are intended to support efforts in maintaining and improving the quality of care; they have been developed across countries, although the ways in which they are implemented and applied differs between nations. Taking a range of six countries, we review the regulatory mechanisms that have been implemented to ensure that essential standards of care are applied and are being adhered to, and consider the range of policy instruments used to encourage and ensure continuous quality improvement. We report on Australia, England, Finland, Germany, the Netherlands and the USA. The study is intended to inform policy thinking for the Department of Health and others in developing the regulation of safety and quality of health and social care in England. It was prepared as part of the project "An 'On-call' Facility for International Healthcare Comparisons" funded by the Department of Health in England through its Policy Research Programme.

Background: Migrant health is receiving increasing international attention, reflecting recognition of the health inequities experienced among many migrant populations and the need for health systems to adapt to diverse migrant populations. In the Greater Mekong Subregion (GMS) there is increasing migration associated with uneven economic integration and growth, socio-economic vulnerabilities, and disparities between countries. There has been limited progress, however, in improving migrant access to health services in the Subregion. This paper examines the health needs, access barriers, and policy responses to cross-border migrants in five GMS countries. Methods: A review of published literature and research was conducted on migrant health and health service access in Cambodia, Lao People’s Democratic Republic, Myanmar, Thailand, and Viet Nam, as well as analysis of current migration trends and universal health coverage (UHC) indicators in the Subregion. The review included different migrant types: i.e. migrant workers, irregular migrants, victims of trafficking, refugees and asylum seekers, and casual cross-border migrants. Results: There is substantial diversity in the capacity of GMS health systems to address migrant populations. Thailand has sought to enhance migrant health coverage, including development of migrant health policies/programs, bilateral migrant worker agreements, and migrant health insurance schemes; Viet Nam provides health protection for emigrant workers. Overall, however, access to good quality health care remains weak for many citizens in GMS countries let alone migrants. Migrant workers – and irregular migrants in particular – face elevated health risks yet are not adequately covered and incur high out-of-pocket (OOP) payments for health services. Conclusions: UHC implies equity: UHC is only achieved when everyone has the opportunity to access and use good-quality health care. Efforts to achieve UHC in the GMS require deliberate policy decisions to include migrants. The emergence of the UHC agenda, and the focus on migrant health among policy makers and partners, present an opportunity to tackle barriers to health service access, extend coverage, and strengthen partnerships in order to improve migrant health. This is an opportune time for GMS countries to develop migrant-inclusive health systems.

To explore the applicability of a patient complaint taxonomy to data on serious complaint cases.Qualitative descriptive study.Complaints made to the New South Wales (NSW) Health Care Complaints Commission, Australia between 2005 and 2010.All 138 cases of serious complaints by patients about public hospitals and other health facilities investigated in the 5-year period.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.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.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.

Drawing on published work from the Asia Pacific Observatory on Health Systems and Policies, this paper presents a framework for undertaking comparative studies on the health systems of countries. Organized under seven types of research approaches, such as national case-studies using a common format, this framework is illustrated using studies of low- and middle-income countries published by the Asia Pacific Observatory. Such studies are important contributions, since much of the health systems research literature comes from high-income countries. No one research approach, however, can adequately analyse a health system, let alone produce a nuanced comparison of different countries. Multiple comparative studies offer a better understanding, as a health system is a complex entity to describe and analyse. Appreciation of context and culture is crucial: what works in one country may not do so in another. Further, a single research method, such as performance indicators, or a study of a particular health system function or component, produces only a partial picture. Applying a comparative framework of several study approaches helps to inform and explain progress against health system targets, to identify differences among countries, and to assess policies and programmes. Multi-method comparative research produces policy-relevant learning that can assist countries to achieve Sustainable Development Goal 3: ensure healthy lives and promoting well-being for all at all ages by 2030.

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'.

Item does not contain fulltext This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.

Social work was stereotyped as women's work until more men began to enter it in the late 1960s. But the sex balance has swung back according to census data. Among those stating social work as their occupation, the proportion of men declined from one-third to one-quarter between 1976 and 1986. The total number of social workers also declined between 1981 and 1986. The apparent male exodus from social work may be because men have left, or been promoted to managers, or prefer to avoid a perceived gender stereotype in the title social worker. The social work profession once again has a problem with sex segregation and gender stereotyping in the labour market.

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.)

We administered an electronic survey in October? November 2006 to gauge stakeholder perspectives on Australia?s recently adopted health workforce policies. Nearly all of the 41 survey respondents (65% response rate) ranked workforce as very important to overall health policy. Respondents identified decreasing health disparities and rates of disease and mortality as top goals, and identified improved quality and safety and more professionals in rural areas as priority measures for success. Lack of coordination between the governments and insufficient long-range planning were seen as threats to the success of the new workforce initiatives. The survey results suggest the need for clear goals and measurable outcomes. Although they represented different organisations and perspectives, the health workforce policy opinion leaders that participated in this survey reflected remarkable commonality in goals, measures, alternatives, and potential threats.

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.

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'.

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.

Most social workers in Australia are women – nearly two-thirds according to the 1976 census. More men have been entering the welfare industry, but the distribution of men and women in welfare is different. Data mainly from the 1976 census, indicates a similar pattern to that reported overseas: within welfare there is ‘men's work’ and ‘women's work’, and women are under-represented in the higher career and salary ranges.

Surveys of the aged in Australia are characterised by a limited discussion of the methodology. However it is essential, especially in surveys aiming to discern levels and types of need among older populations, that the degree of representativeness of the survey be clearly established. A move towards needs-based service delivery systems in Australia will depend upon relevant information being collected from representative samples of older people. The methodology for such data collection needs to be improved. This paper reviews various sampling strategies, and reports upon the methodology employed in obtaining and interviewing a random sample of people aged 70 years or more living at home in Adelaide's “middle suburbs”.

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.