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Section A - Policy

11. Major Service Reviews

11.1 Trauma and Emergency Services

In 1997 the Minister for Health established a Ministerial Taskforce on Trauma and Emergency Services to advise government on a best practice model responsive to the identified needs of critically ill trauma patients. The Report of the Taskforce Review of Trauma and Emergency Services - Victoria 1999 was released by the Minister for Health in April 1999.

The Taskforce, in association with the Working Party on Emergency and Trauma Services, and specialist sub-groups developed an extensive and comprehensive approach to management of trauma in Victoria. Trauma care is highly complex and improvement in trauma outcomes requires a system-wide approach to optimise service delivery, including:

  • Integration, co-ordination and inclusiveness of providers in system planning and maintenance;
  • Designation of hospitals to receive major trauma;
  • Concentration of expertise in trauma management;
  • Compliance with triage and transfer protocols;
  • A rapidly responsive medical retrieval system for time critical cases; and
  • Quality management structures.

    • The Taskforce has recommended a four tier integrated system, called the Victorian State Trauma System, with different complexities of trauma care provided at each level of the system. The service delivery system will consist of Ambulance Services and designated trauma hospitals. It will be driven by three Major Trauma Services (two adult and one paediatric) and supported by two levels of trauma and injury management services in Metropolitan Melbourne and three levels in regional Victoria. All levels will be linked through agreed triage and transfer guidelines and protocols.

    The Taskforce’s recommendations will be progressively implemented by all trauma and emergency service providers while ongoing system development will be overseen by:

    • A newly established Ministerial Emergency and Critical Care Committee;.
  • A subcommittee called the State Trauma Committee; and
  • A Victorian Trauma Foundation (a separate legal entity).

    • System development will also occur through these groups working with two implementation arms, the Trauma Services Project Unit and regional Consultative Committees on Emergency and Critical Care (CCECCS).

    The Department will be supporting the establishment of the system through a range of initiatives over 5 years. The Department will be supported by the Transport Accident Commission (TAC) who will provide significant funding to ensure optimal outcomes. Funding will be provided both via the Departments normal purchasing processes as well as direct funding for specific purposes. Direct funding will be provided for items such as system evaluation and quality monitoring, education and training, retrieval services, co-ordination activities and communication infrastructure.

    The Victorian Trauma Foundation will be created as a separate legal entity to support the recommendations of the Ministerial Taskforce. It is to be chaired by a TAC representative responsible for recommending to the TAC the proposed allocation of funds provided by the TAC for the purposes of:

    • Monitoring the trauma system;
  • Education and training;
  • Triage and transfer of patients initiatives;
  • Clinical management initiatives;
  • Retrieval and transferring initiatives; and
  • Research, services and technological developments for trauma.

    • The Victorian Trauma Foundation will not fund infrastructure. The Foundation is expected to be set up by 1 September 1999 and its initial membership will draw upon a wide range of stakeholders with knowledge and expertise in trauma management.

    It is essential that the Departments purchasing policies support and complement desired clinical practice. The Department, in partnership with TAC, will in 1999 - 2000 both amend some existing policies and introduce new initiatives. These changes are summarised below:

      11.1.1 Funding Initiatives

      • WIES utilised in the treatment of TAC patients will be disaggregated from private patient WIES allocation and will be uncapped for the treatment of TAC patients.
      • Revenue targets for TAC income will be removed from individual hospital budgets. The risk for achieving total annual TAC income will be accepted by the Department.
      • The Alfred Hospital, the Royal Melbourne Hospital and the Royal Children’s Hospital will receive a Minimum Throughput Payment for TAC patients.
      • Financial incentives will be provided to the major existing trauma hospital, the Alfred Hospital, to increase the number of appropriate TAC trauma patients. There will conversely be financial disincentives if the number of patients fall below the current level.
      • A trauma appropriateness payment (TAP) of $2,000 per patient will be paid to a referring hospital for each trauma patient appropriately referred to a major trauma service hospital. This includes both TAC and non-TAC trauma patients. This payment will increase to $3,000 for rural hospitals in recognition of higher transport costs. TAP claims from hospitals will be subject to regular monitoring and audit to prevent inappropriate transfers or financial gaming.

        The above changes have not been incorporated into modelled budgets. Hospitals will be advised by 31 July 1999 of resultant changes to both revenue and throughput targets. The changes will not affect the overall underlying net position of hospitals as modelled. Hospitals can however, expect a better than modelled result as a result of the incentives.

      11.1.2 Service Initiatives

      • Establishment of Major Trauma Services as centres of clinical excellence at the Alfred, the Royal Melbourne Hospital and the Royal Children’s Hospital, providing expert care to major trauma patients from resuscitation through acute and post acute phases. This includes provision of 24 hour consultant led trauma response.
    • Establishment of a comprehensive monitoring system incorporating the initial ambulance service through to treatment of trauma patients at all hospitals. This system will be designed to ensure that evaluation of the progress against the objectives of the Ministerial Taskforce are closely monitored and evaluated.
    • Establishment of the Trauma Services Project Unit which will be responsible for implementing key system wide initiatives, including development of the central trauma data registry which will monitor activity.
    • Targeted educational strategies for:
    • MICA and ambulance paramedics and Emergency Department staff regarding proposed triage and transfer guidelines; and
    • Rural MICA and ambulance paramedics and medical and nursing personnel regarding principles of trauma management.
    • Communications systems enabling rapid referral and transfer advice to anywhere in the state from the Major Trauma Services.
    • Enhanced coordination and response capacity of state wide medical retrieval services through:
    • Improved access to aircraft;
    • Improved retrieval coordination and integration mechanisms;
    • Improved access to appropriate levels of escort according to clinical need; and
    • After hours staffing of Air Ambulance Victoria switchboard.
    • Targeted rural initiatives including:
    • Appointment of a Regional Retrieval Coordinator to promote regional retrieval service integration;
    • Shifting the burden of retrieval costs away from the referring hospital; and
    • Funding in the 1999 - 2000 budget to provide project support to the regional Consultative Committees on Emergency and Critical Care Services in their expanding and pivotal role in rural trauma system implementation and development.
    • Dedicated trauma research lead by the Victorian Trauma Foundation, the State Trauma Committee and Trauma Services Project Unit.

    11.2 Evaluation of the Relocated HIV/AIDS & Infectious Diseases Services

    In 1995, Fairfield Hospital was closed with HIV/AIDS and infectious disease services relocated to the Alfred Hospital and Royal Melbourne Hospital, respectively. An independent evaluation was undertaken in 1998 - 99 following a commitment made by the Minister for Health to review the relocated HIV/AIDS and infectious diseases services.

    The Evaluation of the Relocated HIV/AIDS and Infectious Diseases Services conducted by Health Outcomes International Pty Ltd, 1999 was overseen by an Advisory Committee that included the Alfred Hospital and the Royal Melbourne Hospital, independent experts, and consumer representatives. It reviewed the range, appropriateness and acceptability of the HIV/AIDS and Infectious Diseases Services and made recommendations concerning future service development strategies, purchasing policy and ongoing monitoring and evaluation of services.

    The consultants recommended a number of service improvements that will be implemented by the agencies within existing budget allocations. The Department has adopted the report’s funding recommendations and will continue block funding of the HIV/AIDS services at the Alfred Hospital, and the infectious diseases services at the Royal Melbourne Hospital, at current levels for 1999 - 2000.

    The Department, in consultation with providers and consumer representation, will undertake development work in 1999 - 2000 investigating alternative funding models incorporating the principles of:

    • Funding of direct patient care service on the basis of activity;
  • Recognition of the significant component of the services relating to State-wide support, research, education and training;
  • Facilitation and encouragement of flexibility of service mix, including inpatient, outpatient and community-based services, consistent with contemporary models of best practice; and
  • Stability of funding.

    • 11.3 Review of Radiotherapy Services

    The Review of Radiotherapy Services, Victoria undertaken by ACIL Consulting was released by the Minister for Health in May 1998. The Review was initiated by the Department to provide an analysis of the options and provide recommendation for the future development of radiotherapy services in Victoria. The ACIL Report analysed the present and projected demand for these services, identified the costs associated with radiation oncology, and presented models and options for future service provision.

    The key recommendations of the ACIL report include:

    • The need to improve access to radiotherapy services of patients, as well as the trial of a single machine unit site in rural Victoria;
  • The need to increase radiotherapy utilisation rates by cancer patients to 50-55 per cent, in line with Australian Health Technology Advisory Committee recommendations;
  • The greater involvement of the private sector in delivering these services; and
  • A changed role for tertiary centres, in providing ‘hub services’ in the form of consultation and planning services to ‘spokes’.

    • The Department sought comments from the field and convened an expert advisory committee to advise on implementation of the review. The Department’s objectives have been identified as being:

    • To increase utilisation rates of radiotherapy to meet world’s best standards;
  • To improve access to radiation oncology services for all Victorians, particularly those living in rural and outer metropolitan regions. In order to improve access to services in rural areas a trial of single machine unit sites will be undertaken;
  • To seek to address the demand for services based on priorities, within a five year investment plan. The two high priority regions requiring services are the Western and Southern Metropolitan Regions;
  • To maintain centres of excellence; and
  • To maximise involvement of collocated and private sector radiotherapy services, while maximising integration with existing providers.

    • In 1999 - 2000, these policy objectives will be pursued through:

    • Purchasing more accessible radiotherapy services for Victorian public admitted patients from the Upper Hume region of the State, through the Murray Valley Private Hospital, Wodonga. Some 170 WIES will be purchased in 1999 - 2000, to be reviewed on an annual basis;
  • A joint Commonwealth / State Radiotherapy Single Machine Unit Trial was announced in September 1998 by Minister Wooldridge and Minister Knowles. Three sites in rural Victoria, Ballarat, Bendigo and La Trobe Valley, will be part of this Trial with some services expected to commence in the 2000 - 2001 financial year. The State and Commonwealth have established a Steering Committee to oversee quality and monitoring aspects of the trial;
  • Planning information on radiotherapy services will be improved through the development and introduction of minimum reporting data set for public and private radiotherapy services, covering inpatient and outpatient treatments;
  • Additional staffing requirements through the expansion of radiotherapy services will be supported through the creation of additional registrar training positions. Radiation therapist and radiation physicist requirements will be addressed by separate workforce studies; and
  • A review of the funding mechanism for radiation oncology will be undertaken and finalised before the end of the 2000 - 2001 financial year. A separate review of Health Program Grant funding is currently being undertaken by the Commonwealth Government.

    • 11.4 Breast Care Redevelopment

    The Breast Care Implementation Advisory Committee has provided direction for the development of best practice services for breast care in Victoria over the next five years. The Committee identified nine Key Action Areas as priorities for redevelopment, and recommends the establishment of an organisational structure to oversee implementation. The BreastCare Victoria Coordination Unit was set up in February 1999.

    A major recommendation of the Strategy is the development of a strategic purchasing policy for breast services. As announced in the 1998 - 99 Policy and Funding Guidelines, implementation of purchasing policy reform began in the third and fourth quarters of 1998 - 99, with the establishment of a Breast Services Enhancement Program. Expressions of interest for nine demonstration models for the Program were sought in early 1999, eight of which commenced in 1998 - 99.

      11.4.1 Breast Services Enhancement Program

      The Breast Services Enhancement Program (BSEP) is a purchasing approach which will run for three years, with $2 million committed for 1999 - 2000. The nine demonstration models of enhanced breast care supported by the Program will promote integrated and networked breast care services, with a focus on the implementation of best practice, and improving quality, accessibility and coordination.

      To be eligible to participate in the Program, metropolitan service providers were required to form consortia of public and private service providers. The four funded metropolitan consortia are lead by:

      • North Western Health Care Network (including the Women’s and Children’s Health Care Network);
      • Austin & Repatriation Medical Centre and St Vincent’s Hospital;
      • Inner & Eastern Health Care Network; and
      • Southern Health Care Network (including the Peninsula Health Care Network).

      Regional/rural service providers were asked to collaborate in a Region-wide submission to be eligible to participate in the Program. The five Regional demonstration models are facilitated through the DHS Regional Offices of Barwon-South Western, Loddon Mallee, Hume, Grampians and Gippsland. In 1999 - 2000, $1.1 million will be allocated to these organisations to develop comprehensive breast care service plans; identify coordination mechanisms; and identify a time table for achieving some agreed core outcomes including: local protocols for the use of clinical guidelines; multi-disciplinary care protocols; treatment protocols; mechanisms for peer review; and quality control, continuity of care mechanisms, data management, and provision of trained breast care nurses.

      A further $0.9 million will be allocated to running the BreastCare Victoria Coordination Unit, including the implementation of the high priority actions identified in the Strategy, as well as capacity building to support the Enhancement Program. This includes: the development of an agreed core data set and initiating a pilot program to implement data collection in public and private systems; the development of key performance indicators for breast cancer services at institution and State-wide level; the development of a measuring tool for reporting and trialing consumer satisfaction; surveying current training and education programs and hosting a State-wide conference on breast services.

      The BreastCare Coordination Unit will work with the demonstration models to develop an agreed set of breast care standards and specifications for:

      • Multi-disciplinary care and use of treatment protocols;
      • Clinical data collection and the management of patient information;
      • Protocols for communication and information, and consumer involvement in all aspects of care; and
      • Development of liaison processes with service providers across the care continuum.

      The development of standards and specifications is incremental, and will inform the development of further strategic purchasing approaches and performance benchmarks.

    11.5 Cystic Fibrosis

    Cystic fibrosis (CF) is a lifelong chronic illness that requires high levels of care on an outpatient and inpatient basis. There are three specialist providers of care in Victoria: Royal Children’s Hospital; Alfred Hospital; and Monash Medical Centre. Recognised features of a high quality health care service for patients with cystic fibrosis include:

    • Care delivered at specialist clinics;
  • A multi-disciplinary approach to care that includes regular CF team meetings;
  • Regular planned patient follow-up;
  • Ready access to allied health services, including physiotherapy, counselling services, dietitian services, and social worker services;
  • Care that encourages patient self-management behaviours;
  • Care that includes a significant element of patient education; and
  • Outreach clinics for patients who live in regional or rural Victoria.

    • The Department is currently examining alternative models for funding care for patients with cystic fibrosis consistent with integrated and coordinated care. A study has been commissioned to describe current services and to identify and assess strengths and weakness of alternative purchasing models. This study will provide a basis for a comprehensive purchasing strategy for 2000 - 2001.

    For 1999 - 2000 a specified grant will be provided to the providers of specialist cystic fibrosis care (Royal Children’s Hospital, Alfred Hospital, Monash Medical Centre) for the provision of outpatient physiotherapy, dietetic services and psycho-social care. Grants will be based on an expected average level of services per person and will include a component for additional services provided for patients who have needs beyond preventative and maintenance care. Grants will be provided on an interim basis until the completion of the detailed purchasing strategy for 2000 - 2001 and will be dependent on demonstrated levels of allied health occasions of service. Payments will be made following the submission of quarterly activity reports for CF patients for physiotherapy, dietitian consultations, and counselling occasions of service. Care provided by psychologists or other qualified counsellors who are members of a recognised professional body will constitute a counselling occasion of service.

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