South Australia is fortunate to have one of the world’s most advanced health-care systems. But it is a system that has its challenges.
We interviewed 49 staff in departments/agencies other than Health and five academics with experience of HiAP. Our survey revealed that the supportive policy network developed around HiAP was strengthened by senior policy entrepreneurs outside Health who took knowledge of and enthusiasm for HiAP with them when they moved between sectors.
Background
The State of South Australia, covering a million square kilometres, is home to 1.7 million people. The population is diverse with a significant proportion living in regional locations. These people face a range of structural and attitudinal barriers to accessing healthcare. This research aims to explore these barriers and the implications for healthcare needs, expectations and experiences of people living in regional South Australia.
The research is being undertaken by the Australian Institute of Health and Welfare (AIHW) in partnership with the University of South Australia. It is the largest survey ever conducted to examine the healthcare needs, expectations and experiences of regional South Australians. It will use non-probability sampling for economic and logistical reasons. Participants will be adult health consumers who are resident in a regional, rural or remote area of South Australia, ie have a permanent address and have the ability to read and comprehend written English. Multiple strategies are being put in place to mitigate the risk of sample, undercoverage, recruitment, participation and measurement bias.
The research is examining the determinants of the ability of the public to have timely and equitable access to quality healthcare. The aim is to identify how to create a system that is based on the needs of the public rather than a ‘one size fits all’ approach that favours certain groups over others. It will also explore the need to shift funding from a predominantly acute and emergency care model of healthcare to a more community-based and preventive approach. This will require a change in mindset and a commitment from the state government to a fundamental re-prioritisation of its health system. In order to achieve this a new and more robust approach will be required in which health considerations are built into policy development at the outset. This will require amending the Public Health Act to ensure regulated processes and procedures are in place. Creating such an approach will be difficult but is essential for the long-term sustainability of the state’s health system and the health of its population. A coalition of actors will be required to encourage this process.
Methods
The Commission on Excellence and Innovation in Health (CEIH) has been leading efforts to introduce a state-wide Patient Reported Measures program, centred around people’s own perceptions of the impact of their health condition, their experiences with healthcare services, and whether their health outcomes are improving. Leveraging the digital platform of The Clinician, this initiative will enable patients and clinicians to collect PRMs and share them across the state.
The Malinauskas Government is continuing to invest record funding into a variety of initiatives designed to relieve pressure on our hospitals and address ramping. An investment of $2.3 billion over the forward estimates will see the roll out of new and enhanced primary care and community support services to reduce hospital admissions, ease congestion in our emergency departments, and improve access to specialist care.
These include a new GP Medical Escalation Service that will connect people with a virtual GP to provide a telehealth assessment and e-script, in circumstances where there is no local primary care option available within an appropriate timeframe. It will be delivered by the new Primary Care Pilot funding and is expected to begin in the coming months.
In addition, the new safe@home project, led by Flinders University, will allow chronic disease patients to receive daily primary care services via virtual and remote care services including telemonitoring and a 24/7 telephone helpline. The service will be rolled out in regional SA, where it will be offered free of charge, and in metropolitan Adelaide where the service is being offered as part of a trial to improve chronic disease management in regional SA.
Another initiative is a new Country Referral Unit that will provide fee-for-service ambulance and non-urgent patient transport for people who are unable to travel or cannot safely manage their own health needs in the community. There is also a 24 hour telehealth service for children and young people through Child and Adolescent Mental Health Service (call 13 14 65). Other services include the Country Ambulance Service, which provides fee-for-service emergency medical and non-urgent patient transport, and the Royal Flying Doctor Service offers fee-for-service ambulance and emergency medical flights.
Results
The SA Government has a history of implementing a Health in All Policies approach (HiAP). HiAP has promoted the view that government policy is one way to address the social determinants of health. It has facilitated the development of a policy network and new norms for intersectoral collaboration that are likely to be long-lasting. However, this research suggests that HiAP has also been a vehicle for strengthening the dominant political and economic frameworks that shape its implementation and influence whether or not it will achieve health outcomes.
HiAP’s authorising environment was framed around its focus on government priorities and the requirements for departments to co-operate with each other on these priorities. This strengthened the motivation of departmental chief executives to collaborate on HiAP projects. However, the focus on project-based work meant that it was difficult to sustain a population-wide strategy. There was evidence of reversion to a behaviour-driven approach, and the emphasis on co-benefits reduced the perceived importance of equity outcomes.
In addition, HiAP did not challenge the underlying political and economic structures that determine inequalities. Its actions were aimed at changing daily living conditions but did not seek to redistribute resources or address power imbalances. The lack of a strong equity goal in the context of an adverse employment environment in which casualization and unemployment were rising was a serious weakness.
Despite these challenges, HiAP’s policy network has proved to be resilient and its new norms for inter-sectorial collaboration are likely to be long-lasting. The research has been instrumental in influencing the Foundation to shift its funding practices, moving away from an outcome-based system of grants and towards a more community informed and community led approach. The new model of funding will include the development of a regional health survey and in-depth interviews with local people to understand their needs, expectations and experience of the healthcare system.
The survey will use a non-probability sample to ensure a representative, cross-sectional representation of the population. This will be supplemented with a qualitative component of interviews and focus groups to gain deeper insight into the experiences of local people. The results will be used to inform the design of new strategies that will better meet the health needs of the people of South Australia.
Conclusions
Research has shown that access to quality healthcare services is a fundamental human right, however this doesn’t always happen. In some cases, people who live in regional locations are not able to get the medical care that they need due to a lack of healthcare infrastructure and/or attitudinal barriers. This project will be the first of its kind to examine healthcare needs, expectations and experiences in regional South Australia. It will involve a large survey of regional healthcare consumers and will provide insights into the barriers that prevent regional South Australians from getting the medical help they need. The research has been reviewed and approved by the University of South Australia’s Human Research Ethics Committee and will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media, the internet and various community/stakeholder engagement activities.
The underlying drivers of health inequities are beyond the remit of any single government department and therefore it is difficult to implement strategies that address them. SA HiAP was able to avoid lifestyle drift in policy initiatives through a focus on populations rather than individual projects, by building a strong network of knowledge and policy entrepreneurs, moving away from short term project focus towards institutionalisation through new public health legislation, and finding a fit between its ideas about healthy policy and the dominant economic paradigm of government.
It was unable to impact on the broader underpinning factors of social, economic and power distribution though, because it operated at a level of government that does not control many aspects of resource distribution and was built on consensus with a preference for win-win strategies. Furthermore, many of the policies which would address these underlying issues were likely to be contentious and require strong citizen involvement.
A theory-based program logic approach to causal analysis allows the evaluation of an initiative like SA HiAP and can shape assessment of its impact on actions that are likely to improve population health. While SA HiAP’s contribution to a health-in-all-policies approach was modest, it can be judged as having made a real difference through its work with multiple departments and encouraging them to understand that their policies have health implications.