Section A - Policy
2. Overview
2.5 Trauma ServicesThe Review of Trauma and Emergency Services by the Ministerial Taskforce on Trauma and Emergency Services was released by the Minister for Health in April 1999. It recommended a tiered structure of hospitals to provide differing levels of treatment for patients with major trauma. The Department together with the Transport Accident Commission (TAC) will be supporting the establishment of this system through a range of initiatives over 5 years. Funding will be provided both via the Departments normal purchasing processes as well as direct funding for specific purposes.
The system will consist of Ambulance Services and designated trauma hospitals, and will be driven by three Major Trauma Services (two adult and one paediatric), supported by two levels of trauma and injury management services in Metropolitan Melbourne, and three levels in regional Victoria. All services will be linked through agreed triage and transfer guidelines and protocols.
- Key service initiatives are outlined in Chapter 11 and include:
- Establishment of three Major Trauma Services as centres of clinical excellence, providing expert care to major trauma patients;
- Establishment of the Trauma Services Project Unit, which will be responsible for implementing key system wide initiatives;
- Targetted educational strategies and improved communications systems;
- Enhanced coordination and response capacity of state wide medical retrieval services;
- A number of targetted rural initiatives; and
- Dedicated research into all aspects of trauma.
Two major challenges continue to face acute hospitals in rural communities. The first is maintaining access to specialist services when it is difficult to attract and retain some specialists in rural areas. The second challenge relates to smaller rural hospitals, and involves encouraging these hospitals to provide a wider range of community-based as well as bed-based health services. The policy for 1999-2000 continues the policies established earlier to address both of these challenges. It is desirable that major regional referral hospitals and sub-regional hospitals have an appropriate range of specialist services and that there is good co-operation between regional, sub-regional and smaller local hospitals. Thus rural people can access these services within their local area rather than travelling to Melbourne.
2.6.1 Regional HospitalsThe Rural Specialist Services Grant will continue to foster and maintain specific specialty services in rural regional and sub-regional hospitals. In 1999-2000, funding for each specialty will continue up to $60,000.
For the purposes of grant allocation specialist services include specialist services of general surgery, obstetrics and gynaecology, anaesthetics, and general medicine for sub regional and regional hospitals. For larger rural communities served by major regional hospitals additional specialist services of paediatrics, orthopaedic surgery, psychiatry, geriatrics and rehabilitation and emergency medicine and other specialist services may be supported through the Rural Specialist Services Grant. Further details may be obtained from the Regional Provider Manager. Applications for these grants must be received by the Department prior to 17 September 1999. Applications should be addressed to the Regional Provider Manager.
2.6.2 Other Rural Hospitals
Not all rural areas have access to a range of specialists. Thus it is necessary for general practitioners to assume responsibility for delivering a greater range of services, particularly in the areas of obstetrics, anaesthetics, minor surgery and accident and emergency services. A Continuing Medical Education subsidy program for rural general practitioners commenced on 1 July 1996. The joint contribution to the costs of the program by the Department, hospitals and general practitioners will continue in 1999-2000. The Department's insurance policy will also continue to provide medical indemnity insurance at an attractive rate to a number of rural general practitioners -including rooms-based care and care in many Bush Nursing Hospitals.
The Rural and Isolated Grant has been retained at 1998-99 levels.
In 1999-2000 rural regions will continue their extended role in WIES allocation and Rural Specialist Services Grant recommendations. For 1999-2000, a Rural WIES Transfer Transitional Compensation Grant has been established to smooth the effect of any throughput realignment. Rural regions have responsibility for appropriate service planning and delivery within their region and the tables in Chapter 15 reflect these regional allocations. In some cases this has meant the movement of WIES between hospitals within the region. A compensation grant will be paid for one year, 1999-2000, to assist this transition. This grant does not apply for WIES moved on a temporary basis during the year where hospitals perform under target.
As part of the ongoing improvement in the allocation of funding levels and service planning, the Department has commissioned a study to investigate outpatient and emergency services activity in rural hospitals not funded through the Victorian Ambulatory Classification System. The project will involve the assessment of existing data on non-admitted outpatient and emergency services and will survey and document existing services within the broad hospital groups, including a description of external factors influencing service provision. The project will report in late 1999 and its recommendations will be considered by the Department for 2000-2001.
2.6.3 Healthstreams
The Department has established the Healthstreams Program to enable smaller rural hospitals to participate in more flexible funding and purchasing arrangements. Healthstreams now has 9 agencies approved as participants in the Program with a further 11 agencies approved in principle. These agencies have received Implementation Grants totalling almost $570,000 to date. Considerable interest has been shown by other agencies in participating in this Program. A total of $928,000 in specified grants of reallocated funds was approved in the last financial year.
Flexible funding and purchasing should not shift acute throughput to other acute funded non-Healthstream agencies unless this is warranted on a service basis. Management of Healthstream agencies must ensure that this does not occur and the Department is monitoring activities in this area.
2.6.4 Multi-Purpose Services (MPS)
The conversion of small hospitals to MPS agencies enables considerable and desirable flexibility to these agencies in choosing service delivery mechanisms appropriate to local circumstances. Monies provided previously for acute throughput has been converted to a net grant (i.e. net of private patient and other revenue). The MPS agencies will be subject to ongoing Acute Program policies in respect of further funding. The agencies will be entitled to an appropriate share of additional growth and capital expenditure allocations. Similarly, the agencies will be subject to the same policy decisions on private patient revenue and productivity requirement as smaller hospitals which remain in the Acute Program. Monitoring arrangements will be implemented to ascertain whether acute throughput has been merely shifted from an MPS to another acute funded agency and if so an appropriate funding adjustment will be made.
2.7 National Health Development Fund
The Australian Health Care Agreement includes a new pool of funds known as the National Health Development Fund. The objectives of the Fund are to:
- Improve patient outcomes;
- Improve the efficiency and effectiveness of public hospital services;
- Reduce the demand for public hospital services; and
- Improve integration of care between public hospital services and broader health and community services.
Over the next five years, $63 million is available to Victoria. The Victorian National Health Development Strategic Plan comprises nine programs focused around the following five reform themes of appropriate triage and referral, strengthening consumer information, strengthening health communications technology, re-engineering structural reform and developing a skilled workforce.
The programs include:
- Innovative clinical and consumer information management;
- Integrated disease management strategy;
- Information, information management, information technology and telecommunications in the primary health and community support sector;
- Health information, support and referral telephone service;
- Re-engineering health care;
- Innovative financing models and applications;
- Capacity building for Aboriginal health service provision;
- Rural health education, training and support; and
- Workforce and infrastructure initiative for health promotion and disease prevention.
As part of a major reform proposal under the Australian Health Care Agreements, the Commonwealth has offered the States and Territories access to Pharmaceutical Benefits Scheme (PBS) reimbursement for hospital initiated prescriptions for non-admitted patients and admitted patients on discharge. Under the proposal, the Commonwealth will meet the costs for hospital initiated prescriptions up to the rate of growth for non-hospital initiated PBS prescription, with hospitals meeting half the costs in excess of that growth rate. In sharing the excess growth, hospitals will have an incentive to maintain an active role in the oversight of hospital PBS prescribing to ensure that the growth rate is kept to a minimum. Hospitals will receive regular data feedback on their prescribing rates to assist in maintaining control over growth.
The Commonwealth have also agreed to move a range of chemotherapy agents from the PBS to the Highly Specialised Drugs Program (s100) to allow for access for patients who need to be admitted on a day only basis for the sole purpose of receiving their treatment. The chemotherapy drugs included will be those antineoplastic agents that require infusion. A full list of drugs will be provided at a later stage. Under this proposal, the Commonwealth will meet the cost of these drugs up to an agreed amount, with hospitals meeting half the cost in excess of the agreed amount.
In order for hospitals to receive reimbursement for PBS prescribed and dispensed medications, hospitals will need to ensure that the appropriate IT infrastructure is in place to send and receive claims from the Health Insurance Commission (HIC). It is likely that the Highly Specialised Drugs Program will also move to direct claiming with the HIC. Networks and hospitals will be notified of the full details of the reform package as soon as agreement has been reached.
2.9 Hospital Purchasing, Tendering and Contracting
As public statutory bodies, hospitals are accountable for the expenditure of public funds. This also applies where hospitals make business decisions to outsource functions or purchase goods or services externally.
The prevalence of outsourcing requires hospitals to establish clear purchasing policies and procedures and effective and efficient purchasing practices. The Department expects hospitals to have in place and maintain adequate systems to ensure that all external purchasing processes and decisions are accountable. These systems, policies and procedures should be subject to ongoing monitoring and review, and hospitals should continually strive to achieve best practice in purchasing.
The following principles and practices must be adopted for all external purchasing processes:
Accountability: Hospitals are accountable for their purchasing decisions and processes and for the expenditure of public funds. Hospitals remain accountable for the ongoing performance of outsourced or sub-contracted services.
Fair Competition: Purchasing processes must be open and fair to ensure that all potential and appropriate suppliers have the opportunity to do business with hospitals.
Probity: All purchasing processes must be conducted with integrity and honesty. This includes a duty to be scrupulously even-handed in all dealings; to afford equal treatment to all parties; and to ensure that there is no unwarranted bias in favour of any supplier or potential supplier.
Transparency: Hospitals have a duty to ensure that purchasing requirements and criteria are specified clearly and that identical information is provided to all parties and stakeholders understand how decisions are made. All stages of the purchasing process must be adequately documented to enable effective auditing to be carried out.
Ethical Conduct: All purchasing processes must be conducted in an ethical manner. This includes the duty to avoid real or perceived conflicts of interest; to ensure that gifts or favours are not accepted from suppliers or potential suppliers; and to respect commercial confidentiality.
Value for Money: Value for money must be the principal criterion for all purchasing decisions. Specifications and contracts must be designed to ensure that standards of patient care are enhanced or maintained where services which impact on patient care are subjected to contestable processes.
Clinical Costing: Full clinical costing systems must be maintained, even where services are sub-contracted, and must be able to track to end products and continue to monitor intermediate service costs (e.g. labour, medical, nursing, food).
Where a decision is made to source goods or services from an external supplier, a judgement must be made in each case as to whether the benefits of a public tender process outweigh the costs. However, the Department expects hospitals to have transparent criteria which guide such decisions. For example, Victorian Government Purchasing Board Guidelines applicable to Government Departments require three quotations to be obtained for simple purchases over $2,000 and a public tender process for purchases over $100,000.
Guidance about best practice in tendering and contracting can be obtained from the Victorian Government Purchasing Board's Internet site (http://www.vgpb.vic.gov.au/ vgpb/contents.htm).
Circumstances (including industrial action), beyond the reasonable control of hospital management, may sometimes prevent the attainment of targetted throughput. In previous years, in these circumstances, the Department has, on a case by case basis, funded hospitals according to their cash flow projections irrespective of throughput, only for so long as force majeure continues. Hospitals are expected to mitigate their financial exposure and throughput decline during and following such events and will not be additionally funded for extra "catch-up" throughput in specific service areas undertaken around a period of force majeure. The relevant quarter's performance together with other available data and indicators will be used to determine the net impact of any period of force majeure.
2.11 Major Changes in Services Provided
Funding is provided to hospitals and Networks on the basis that the current range of services are continued. Before hospitals or Networks undertake a significant change in the range or scope of services, the planning implications of such a move must be discussed and agreed with the Department. In rural areas the appropriate discussion should be held with the Regional Provider Manager or Acute Health Manager. In the metropolitan area, discussions should be held with the Acute Health Program and the Region. In all cases, the Director of Acute Health Division must provide the final approval.
The management of risk within hospitals is primarily the responsibility of hospital management who have the ability to identify and remove or ameliorate hazard. As a part of a risk management program the Department has taken out various insurance coverages. The cost of these coverages for the period 1999-2000 is $32 million. Insurance coverage is the final component of a risk management strategy and is not to be considered as an alternative to responsible management action.
The Department will develop, in consultation with hospitals, a position on the excess to be borne by hospitals in respect of claims on the various policies held by the Department for implementation from 1 January 2000. Hospitals will therefore carry a portion of the financial risk from hazard management over which they have control.
2.13 Performance Accountability
The operation and maintenance of a functional costing system is a requirement for good internal hospital management and for cost weight development. Funding is provided to Networks and hospitals on the basis of achievement of best practice and efficient reporting of costs and services provided. Hospitals are required to account for costs and effectiveness of services at the patient level. A component of funding provided for throughput is therefore provided on the basis of responsiveness and precision of clinical costing and clinical management information systems.
In 1999-2000, penalties will be applied where adequate reporting of costs at a patient level are not available for system monitoring or cost weight development purposes. These penalties will be based on the average cost of operating an appropriate clinical costing system according to the operating size of the agency.
In order to enhance the capacity for patients to receive sensible and consistent health promotion and illness prevention messages, together with illness care, selected outer suburban hospitals with emergency departments (all E2 hospitals with the exception of St. Vincent's Hospital and including Maroondah Hospital) will receive $85,000 each to establish health promotion support centres focussing on emergency care. These centres are intended to provide teaching and resources for mainstream staff-importantly the very large number of hospital staff who rotate through emergency departments. It is intended that opportune health promotion be encouraged as part of emergency care, where appropriate-not an activity conducted by "someone else".
Hospital waiting areas will also be provided with dedicated internet facilities, allowing patients and visitors to explore the Better Health Channel, which will progressively provide a wealth of information on good health, illness, care options, and available services.