Foreword
The Queensland Government is committed to the provision of quality health services to all Queenslanders including communities living in rural and remote parts of the State. Delivery of a range of core health, aged care and community services to rural and remote communities poses particular challenges for government. The Queensland Health Multipurpose Health Service (MPHS) Program aims to provide an integrated approach to service provision across government, and also establishing partnerships with other service providers in the non-government, local government and private sectors. The MPHS Program is focused on engaging service providers and local communities to work together to improve service delivery to rural and remote areas.
This discussion paper aims to seek your views on key issues in relation to Queensland Health’s policy position for MPHSs and the Commonwealth’s Regional Health Service Program, which will incorporate MPHSs. The views expressed in this discussion paper do not commit the government to a particular direction for future action. However, the feedback obtained on the paper will inform the development of Queensland Health’s policy position for MPHSs in the future. I encourage you to consider the issues explored in the discussion paper, and provide your comments to Queensland Health.
Wendy Edmond MLA
Minister for Health
Introduction: Rural Health in Perspective
The last two decades have seen significant change in the demographics of rural and remote communities across Australia. An overall decrease in populations in these communities has been accelerated by significant economic changes in the agricultural sector including increased volatility in prices on the world market, and adverse weather conditions (droughts and floods).
Rural communities in Queensland, as in other parts of Australia, are declining due to lack of employment opportunities, and many young people are moving to regional and urban centres to pursue educational and employment opportunities. This has led to an ageing of these communities, which has increased the need for access to support services to enable older people to continue living in their own homes and maintain their independence.
A consequence of this population change has seen a corresponding reduction in services provided in small rural and remote communities by the private sector. There has been no corresponding reduction in the provision of health, aged care and community services provided by the State Government. A major challenge to governments is to maintain and where possible, enhance access to a core range of services suitable for delivery in small rural communities.
It has generally been acknowledged that the key benefit of the MPHS program lies in facilitating the provision of a more flexible range of health and community care services in rural communities. This has been reflected in the joint National Rural Health Policy Forum/National Rural Health Alliance (1999) document ‘Healthy Horizons: A Framework for Improving the Health of Rural and Remote Australians’, which was launched at the National Rural Health Conference in March 1999. The fact that there is poorer health status across rural, regional and remote Australia than in metropolitan areas has also been widely acknowledged. ‘Healthy Horizons’ identified the major issues confronting health service providers as including:
• Age standardised death rates are higher in rural, regional and remote areas than in metropolitan areas.
• Death rates are higher in remote areas than in rural and regional areas, partly due to the high proportion of Aboriginal and Torres Strait Islander people in remote areas.
• Individual and family care needs arising from mental health problems are an increasing cause of concern.
• Suicide and attempted suicide of at risk groups are serious issues within many rural, regional and remote communities.
• More people in rural, regional and remote areas than in metropolitan areas are hospitalised for diabetes and its complications. Aboriginal and Torres Strait Islander people have high and increasing rates of diabetes.
• Death rates and hospitalisation from injury are significantly higher in rural, regional, and remote areas than in metropolitan areas.
• The impact of stroke, heart and vascular disease is significantly higher in rural, regional and remote areas and reflects difficulties in instigating prevention programs in communities with poor access to fresh food, and establishing comprehensive rehabilitation services in small and isolated communities.
• Issues of healthy ageing and health care and support for children and young people have also been identified as needing special attention.
The challenge for the Queensland Government is to develop and implement innovative and flexible solutions to the provision and enhancement of a range of services for people living in rural and remote parts of the State. In order to achieve this, it is essential that the State work in partnership with the Commonwealth, local government, and other service providers including private and non-government organisations and local communities. The Multipurpose Health Service Program represents an approach to integration and flexible service delivery which aims to better meet the health, aged and community care needs of rural and remote communities.
The MPHS Program is consistent with the Queensland Health Corporate Plan 1999-2004 which identifies as a key output of public health services the ‘provision of integrated, specialised community and population wide responses to the protection of health, prevention of disease, illness and injury and the promotion of health and well being’.
Policy Context for Multipurpose Health Services
Bilateral Agreement for the Regional Health Services Program
Queensland Health has signed a Bilateral Agreement with the Commonwealth Department of Health and Aged Care, which provides the foundation for collaborative effort between the two departments for the Regional Health Services (RHS) Program. The Bilateral Agreement sets out the respective roles, responsibilities and arrangements for the delivery of Regional Health Services in rural and remote Queensland.
The Minister for Health, Mrs Wendy Edmond, and the Commonwealth Minister for Health and Aged Care, Dr Michael Wooldridge, have jointly agreed a number of rural communities in Queensland to be developed as Regional Health Services. A list of these sites is at Attachment 2 including MPHSs which are already established in Queensland.
Commonwealth Regional Health Services Program
In the 1999/2000 budget, the Commonwealth announced the establishment of a new program called the Regional Health Services (RHS) Program. Under the RHS Program, new funding of $42.8m over four years will be provided nationally for the establishment of RHSs. This program is intended to bring together a number of existing initiatives including:
• Multipurpose Centres
• Multipurpose Services and
• The Rural Multipurpose Health and Family Services Network.
The aim of the RHS program is to improve access to quality primary health care services. Commonwealth funding for RHSs will be directed towards enhancing the provision of primary health care services in rural communities, including:
• Rural health promotion
• General Practitioner services
• Illness and injury prevention
• Substance abuse and misuse
• Women’s health
• Children’s health
• Community nursing
• Aged care
• Community based palliative care
• Mental health
• Podiatry
• Radiology
• Immunisation
• Public health
• Allied health
The Commonwealth announced on 9 May 2000, as part of the 2000/2001 Federal Budget, additional funding of $68.9M over four years to establish 85 additional RHSs nationally. This new funding provides additional opportunities for Queensland Health to access Commonwealth funding to enhance the provision of health, aged and community care to people living in rural and remote parts of the State.
This discussion paper identifies the key issues to be considered by Queensland Health in articulating a policy statement in relation to the development of MPHSs and RHSs in this State. A Queensland Health policy statement in relation to MPHSs is intended to provide the framework to ensure statewide consistency and at the same time, allow scope for local innovation and the development of service models to suit local circumstances.
‘Healthy Horizons’ states that the successful development and implementation of national strategies for health improvement in rural, regional and remote Australia will require a focus on the following:
• Prevention of illness and the promotion of the health of individuals and communities
• The establishment of partnerships among communities, service organisations, professional groups and governments, and
• Quality and effectiveness to determine the use of models of service delivery, clinical treatment and community development.
Until the establishment of the Multipurpose Health Service Program, there was no formal program for enhancing service integration, as acute, health, aged and community care services remained separately planned, managed, and delivered.
The Commonwealth Department of Health and Aged Care established the Multi-Purpose Service Program as a joint Commonwealth/State initiative to respond to difficulties in providing health and aged care services to smaller rural and remote communities.
Under the MPS (or MPHS as it is known in Queensland Health) program, two services were initially established in Queensland as pilots under the Commonwealth Program. The Commonwealth provided small capital funding contributions towards these MPHSs established at Clermont and Cooktown. No further capital funding has been made available by the Commonwealth for MPHSs nationally. Additional MPHSs have been established in Queensland, at Quilpie, Dirranbandi, Munduberra, Texas, Inglewood, Mossman and western Queensland under the Commonwealth Regional Health Services Program. These services reflect a range of approaches to service integration.
Queensland Health MPHSs: a service integration model
The essence of the MPHS model is to forge better linkages between existing services as well as to enhance services to ensure that the health, aged and care community care needs of people living in small rural communities are met in the most appropriate way. The model provides for the coordinated management of services. The services which make up a MPHS do not have to be collocated, may include outreach and visiting services and are administered as a single integrated service.
The Multipurpose Health Service (MPHS) program is based on a service integration model and is designed to enable the provision of a range of health and community services in a flexible and cost effective way in small rural communities. The MPHS model provides a means to ensure the ongoing viability of services in these communities which otherwise may not be financially sustainable as separate entities.
Although the Commonwealth Department of Health, at the inception of the MPHS program in 1994 provided small amounts of capital funding towards the cost of redeveloping two small rural hospitals in Queensland, the MPHS model is not based or contingent on constructing new buildings. It is aimed at improving the planning, coordination and delivery of a range of services in a flexible way to best meet the health, aged and community care needs of rural communities.
The MPHS model has been identified by Queensland Health as the preferred model for the delivery of health and aged care services in areas in which the hospital’s budget is below $2M per annum (as at 1997/98 financial year). The small population base in these communities serviced by these facilities do not attract the investment and interest of private providers and it is difficult to justify the costs associated with the provision of separate hospital and residential aged care facilities and associated infrastructure. Overall, 49.5% of the beds occupied by nursing home type patients in Queensland public hospitals are located in these small, rural hospitals.
Ten Year Indigenous Planning Framework Project
The Queensland Government seeks to establish a ten year planning framework which will be taken into account in the development of strategies with respect to Indigenous peoples throughout Queensland. This work will inform each line agency and will provide the basis for negotiating partnerships between state agencies and Indigenous peoples in all settings throughout the State. The goals of the ten year planning framework are consistent with the Multipurpose Health Service and Regional Health Services models in terms of fostering cooperation between agencies in the delivery of integrated services.
Aboriginal and Torres Strait Health
The Framework Agreement between the Queensland Minister for Health, the Commonwealth Minister for Health and Aged Care and the Chair of the Aboriginal and Torres Strait Islander Commission sets out the collaborative working relationship between the three parties in relation to the planning and delivery of health services to Indigenous Queenslanders. This Agreement refers to the need to develop and provide innovative service models linking mainstream health services with Indigenous specific health services as well as General Practitioners.
The Partnership Agreement acknowledges that the delivery of health and health related services is a shared responsibility between the parties and that innovative and flexible service delivery solutions are required to ensure access by Indigenous people to health care which recognises their lower health status and higher level of need for services.
A second and complementary Framework Agreement has been signed by the State and Commonwealth Ministers and Chairperson of the Torres Strait Regional Authority. This Agreement refers to the fact that Torres Strait Islander and Aboriginal people living in Torres Strait are recorded as having among the worst health of all Australians and are one of the most disadvantaged groups in the community.
The MPHS program provides a model which is consistent with the aims of these Partnership Agreements, and Indigenous health services can be included as an integral component of MPHS services.
Government Service Delivery Project
The MPHS program aims to improve the coordination and integration of health services in rural and remote communities, and is consistent with the aims of the Queensland Government Service Delivery (GSD) project.
The GSD project was established in response to Government and community concerns about the need for better collaboration and more integrated service delivery approaches in the Queensland public sector. Specific drivers for the project include:
• Community demand for more client focused and responsive services
• Changing government priorities that require cross-agency outcomes
• Demands on the public service for better, more cost effective, coordinated service delivery models
• New and emerging technologies and their potential for improving service delivery and collaboration.
Queensland Health has identified the MPHS Program as an initiative which aims to respond to these drivers of the GSD Project. The MPHS program is also consistent with the introduction across Queensland government of the Managing for Outcomes accrual output budget process which links funding to identified outputs and aims to provide better use of public funds.
Role of Rural and Remote Public Hospitals
Given the changes in recent years occurring in rural and remote communities as outlined above, the role of small public hospitals in these communities has also changed.
With a trend towards shorter lengths of stay due to improvements in treatment, and consumer demand for community support services, the demand for acute hospital beds is changing. The range of services offered by small rural and remote hospitals is also changing, with a greater focus on the provision of primary health care services and ambulatory and aged care services.
Rural hospitals, due to declining populations and changes in treatment are experiencing low occupancy rates. These facilities also have a high proportion of long stay nursing home type patients as the population base does not attract the investment to provide stand alone residential aged care facilities. Rural and remote public hospitals have the capacity to provide designated aged care beds for long stay patients as well as for respite.
The Queensland Health Guidelines for Placing Nursing Home Type Patients (NHTPs) in Residential Aged Care Facilities state that ‘in rural and remote areas where there may be only one or no residential aged care facility it is often appropriate for NHTPs to be managed in the local public hospital as part of a MPHS’.
As the role of small public hospitals in rural and remote areas of Queensland responds to changing demand for some services, the MPHS model offers opportunities for improving the coordination and integration of health, aged and community care programs.
Primary health care
The MPHS model incorporates some acute hospital services, but is essentially based on the provision of primary health care as well as aged and community care services.
The National Rural Health Policy Forum, in ‘Healthy Horizons, A Framework for Improving the Health of Rural and Remote Australians’, defines primary health care as ‘focused on keeping healthy people healthy, improving the health of the community and responding to individuals who need treatment and care.’
Primary health care services include care from General Practitioners, community nurses, Aboriginal health workers, allied health professionals, pharmacists, a range of home visiting services and services provided by family carers.
Under the new Commonwealth Regional Health Services Program, funding will be available for enhancing the provision of primary health care services to rural and remote communities. These services may include outreach and visiting services where it is either not viable (in terms of workload) or not possible to attract fulltime or part time staff in the local community.
Telemedicine is an emerging technology which offers a very useful tool for clinicians and has particular potential to improve access to diagnostic services in rural and remote communities. Telemedicine enables clinicians in remote areas of the State to link to specialist services for diagnostic and treatment advice. This technology could be usefully employed to enhance the range of primary care services available to rural communities under the MPHS model and provide professional support to clinicians.
Draft Principles
The following draft principles are intended to underpin the implementation of the MPHS program in Queensland:
• Sustaining and enhancing services for rural communities
The Queensland Health MPHS program has two aims: to sustain current levels of health and community service provision to rural and remote communities, as well as to enhance the range of services available to these communities.
Small rural and remote communities face particular difficulties in sustaining a range of financially viable health, aged and community care services. Many rural and remote communities do not have the population base to support stand alone residential aged care facilities, and many nursing home type patients are cared for in rural hospitals. Attraction and retention of health and community care staff is particularly difficult in remote communities, where access to General Practitioner services may be limited or non-existent and the public hospital is the main health service provider.
• Community participation
One of the objectives of the Health Services Act 1991 is to ensure community participation in the planning and delivery of health services to meet community needs. Community participation means more than community consultation and community involvement. Communities need to be provided with the opportunities and skills, either individually or collectively, to identify issues which affect their health. This requires building partnerships between consumers, health service providers, other government agencies and non-government agencies.
The Commonwealth Flexible Care Subsidy Principles 1997 state that for a provider to be eligible to provide aged care services as part of a MPHS, there must be evidence of ‘broad based consultation, including consultation with existing service providers and agencies’.
Community participation should be structured to provide significant and purposeful community involvement. Community participation allows people, both individually and in groups, to exercise their right to play an active role in the development of appropriate health services and in ensuring conditions for sustaining better health.
‘Healthy Horizons’ defines participation as not taking over management decisions for services; but the provision of serious input by all community groups into setting priorities on which services and the community can act. This definition of participation will be used by Queensland Health for the purposes of this discussion paper. The rapid appraisal planning process currently used for identifying local needs for health and other related services by Queensland Health provides the opportunity for the community and its representatives to have a say in how MPHS services are shaped and delivered.
• Equity of access
There are a number of well recognised strategic disadvantages in terms of achieving equitable access to health and community services for people living in rural and remote communities. These include:
• Isolation from mainstream services
• Cost effective delivery of discrete services to small populations
• Lack of local residential and community aged care services
• Inflexibility in funding arrangements and
• Duplicated and inconsistent accountability requirements.
It is difficult to attract and retain health professionals in rural and remote communities, which limits access by local residents to these services. ‘Healthy Horizons’ refers to data collected by the Australian Institute of Health and Welfare in 1998 which shows that in relation to General Practitioner services, the use of these services declines steadily with increasing rurality and remoteness; and not suprisingly, the supply of practitioners declines similarly.
Priority attention also needs to be paid to ‘at risk’ and vulnerable groups in the community to ensure greater equity of health outcomes. In particular, improving the health status of Indigenous Queenslanders is a high priority for Queensland Health and one of its three key strategic directions.
The MPHS Program provides a model to address the major disadvantages faced by rural and remote communities to enhance access to a range of health, aged and community care services through the implementation of flexible, innovative and integrated services.
• Partnerships
The success of the MPHS model is contingent on establishing effective partnerships, both between service providers as well as with consumers, carers and local communities. For public services, this means establishing partnerships with a range of State and Commonwealth Government Departments responsible for the delivery of services to people living in rural and remote areas of Queensland, as well as non-government, local government and private service providers.
A partnership approach involves working together to identify needs, and developing a service mix which is appropriate in meeting these needs.
Through establishing MPHSs with a single management structure, service providers are provided with the opportunity to work together to plan and deliver services which are best suited to the identified needs of the local community. This management structure would consist of a small group of Queensland Health service providers. Under current arrangements, if Queensland Health is the auspicing body, this group, and ultimately the District Manager, will be responsible for the administration of the MPHS funding with input from an advisory group consisting of other service providers and consumer representatives.
Key MPHS Implementation Issues:
There are a number of key issues to be considered in developing a policy statement for Queensland Health in relation to MPHSs. These are outlined below and aim to promote discussion with a view to establishing a Queensland Health policy position.
1 Multipurpose Health Services: scope
In order to maximise access for people living in rural and remote communities in Queensland, the MPHS model necessarily must encompass the broadest possible range of services. This will allow for MPHSs to be developed which are responsive to locally identified needs, and shaped through active involvement by community representatives.
To date, in Queensland, MPHSs have incorporated a range of health, aged care and other services including:
• State funded hospital and community health services,
• Commonwealth funded residential aged care
• Community Aged Care Packages (CACPs) and
• Home and Community Care (HACC) services.
There is considerable potential to expand the range of providers included in a MPHS in Queensland. In the context of the Government Service Delivery Project, which aims to improve the coordination and delivery of services across Government, there are many other programs which could be considered for inclusion in a MPHS. Some of these may include:
• privately operated or non-government services
• ambulance services
• respite care
• disability services
• health promotion and prevention programs (breast and cervical screening)
• mental health services
• community transport services
• not for profit service providers
• Divisions of General Practice
• other State and Commonwealth government services
There is also scope for negotiating with the Commonwealth to include other social services within MPHSs (ie. Centrelink, Carelink, disability and childcare programs) as well as with private sector and non-government providers. The range of services to be incorporated in a MPHS is determined through a formal needs assessment process undertaken with service provider representatives as well as community members at the local level. Consequently, MPHSs may be quite different in scope in each community as they are established to meet locally identified service needs.
2 Planning process
Planning for future MPHSs will require a whole of government approach including State Departments such as Disability Services, and Families, Youth and Community Care, Housing, Emergency Services, and others in order to maximise the potential of the MPHS model in Queensland. Queensland Health will need to establish formal working arrangements with relevant Departments to allow maximum flexibility for planning at the local level.
Queensland Health, through the Office of Rural Health and Rural Health Training Units has worked with the University of Queensland’s Centre for Primary Health Care to develop a support program to assist communities and health professions to conduct Rapid Needs Appraisal/Service Planning processes for identified MPHSs. This support program has included the development, piloting and implementation of innovative community workshops aimed at empowering the community to participate and to facilitate the planning phase of the development of a MPHS. Planning requires a comprehensive analysis of community profiles and needs. In light of the Commonwealth Regional Health Services Program, the Rapid Needs Appraisal process is to be reviewed by Queensland Health.
Even with universal access to medical and hospital care, differences in health status between different groups of people mean attention must be given to those with special needs. Planning mechanisms are required to ensure that service providers are representative of the demographic profile of the community and that they act in the interests of the most disadvantaged. This means that in the context of competing needs and interests consensus must be reached about which needs should be addressed first. Consensus needs to take into account both the most common health issues facing the community and those of identified smaller disadvantaged groups within the community who may not otherwise come forward, but whose health needs (HIV/AIDS, Indigenous health, mental health) may be greater.
3 Auspice arrangements
In the process of developing a MPHS, it is necessary to identify which of the services will act as the ‘auspicing body’ for the MPHS. This means that an agreed entity receives the funding from the State and Commonwealth departments of health on behalf of the whole MPHS.
Under the Commonwealth RHS Program, there are a range of organisations which can auspice a RHS service, including:
• Voluntary or private non-profit incorporated organisations
• Local government authorities
• Approved providers such as Commonwealth approved nursing homes or hostels
• State/Territory Government agencies.
Queensland Health’s position is that where an identified MPHS includes a Queensland Health service and/or facility, Queensland Health will be the auspicing body for the whole MPHS.
4 Service Integration
There are a number of pressures within the health system which focus the need for an integrated approach to the provision of care. These include ongoing budgetary pressures, the risk of fragmentation of care due to increasing specialisation and emerging patterns of care which rely on the effective coordination of services between several providers in both the public and non-government health sectors. The key to the MPHS model lies in adopting integrated approaches to the planning and delivery of health services to maximise health gain for consumers as well as to streamline and coordinate service delivery.
Better health care integration presents major opportunities for health care providers to develop partnerships which will improve patient outcomes. The term ‘integration’ often has multiple definitions, depending on different professional disciplines and health settings. Health providers tend to define integration according to their own work context, but for the purposes of this discussion paper integration is defined as:
The linking together by various means of the services of two or more service providers to allow prevention, treatment and maintenance of an individual’s or family’s needs in a more coordinated and comprehensive manner.
Integration may be horizontal or vertical within the health system. Horizontal integration links service providers with the same level of health care (ie. within a primary care setting linking general practice with community health and domiciliary care services). Vertical integration links those at different hierarchical levels in the health continuum (ie. primary care with secondary care). While there are different opinions regarding where vertical or horizontal integration provides the greater potential for gain, an integration model must recognise both components.
Physical Location of MPHS Services
Since the inception of the Commonwealth MPHS program, when limited funding was made available for identified pilot sites for capital development there has been a widespread misconception that establishing a MPHS requires new buildings to collocate the services which are to be included in an MPHS.
The MPHS model is about integrating services in rural communities and where possible, enhancing the range of services available to these communities. Although it may be desirable to physically collocate services, this is not essential for the model to work effectively. By establishing strong links between providers in the management structure of a MPHS, the issue of whether services are physically separate is not important to the successful operation of the service as a whole.
Consumer Focus
The consumer is the focal point for service delivery, with the challenge being to ensure that people move appropriately from one access point to another in the most effective and efficient way. Therefore an integrated health care system must demonstrate benefits to consumers as well as to the overall health system and its providers for it to be accepted and implemented.
There are a number of approaches to service integration. Some of these are outlined below (Queensland Health does not have a preferred model):
(i) Collocated MPHS with single management structure and funds pooling
Under this approach, the services which make up a MPHS would be collocated to facilitate integration, as well as having a single management structure and funds pooling.
A MPHS would be established consisting of a single management structure with responsibility for the coordination and delivery of a range of services. This structure would consist of a small group of Queensland Health service providers including the Director of Nursing, Senior Medical Officer and other provider. Under current arrangements, if Queensland Health is the auspicing body, this group, and ultimately the District Manager, will be responsible for the administration of the MPHS funding. This group would have overall responsibility for management decisions for the MPHS including resource allocations to each part of the service, based on the identified needs of the local community. As the needs of community members change, a MPHS should be able to flexibly adapt service provision to meet these needs as they arise. This will require flexible approaches by the management of Queensland Health and other MPHS parties towards industrial relations practices.
The management of the MPHS will receive input from a local advisory group with representatives of each service within the MPHS and consumer representatives from the local community.
The Mundubbera MPHS operates from a single site, located at the former Mundubbera hospital. Not all health providers in Mundubbera are part of the MPHS. Queensland Health capital refurbishment of the hospital has enabled the provision of high level aged care services. There are however, no non-government service providers who pooled funding into this MPHS. A reference group which includes HACC, Blue Care, Disability Support, Meals on Wheels, Queensland Ambulance Service and the Indigenous Health Service provides advice to the Mundubbera MPHS.
Dirranbandi MPHS operates from the hospital site, however there are no non-government providers who pooled funding. High care places are being provided from the hospital, with low care places in the community.
(ii) Single management structure with funds pooling without collocation
This option would be the same as (i), with the exception of collocation, and also involve the pooling of funds for each service forming part of the MPHS into a single pool. The advantage of this approach is the flexibility it offers in terms of being able potentially to move funds between services based on the needs of the local community. For example, if more people require Home and Community Care services to support them in their own homes, funds may be moved from acute hospital care to HACC services to provide the level of service required. A perceived disadvantage of this approach is the potential threat to the budget autonomy of each service component of a MPHS. The MPHSs located at Cooktown, Clermont and Quilpie in Queensland operate under this model.
Clermont MPHS includes funds pooling by non-government providers (Meals on Wheels, Central Highlands Aged and Disabled Association Incorporated, and the private hospital which had low level aged care places). The low care places are now provided from the hostel facility which is located separately from the hospital site. High care places are provided from the hospital site which received State and Commonwealth capital funding for redevelopment as a pilot site. All health providers in Clermont pooled their funding into the MPHS.
Cooktown MPHS has all health and aged care services with the exception of the non-government services pooling their funds.
(iii) Single management structure without funds pooling (ie. separate service budgets)
This option would operate in the same way as (ii) with regard to management of the MPHS, with the difference being that individual service budgets would not be pooled. Through the single management structure, joint decision making can occur between service providers in relation to priorities for services to meet identified needs with advice from the local advisory group.
A possible variation on this model would be a MPHS where some but not all service providers agree to funds pool. In this situation, the MPHS could contract in those separate services. For example, if Home and Community Care services funded by local government do not want to pool, but the MPHS receives additional CACPs funded by the Commonwealth, the MPHS would have the capacity to contract the HACC services into the MPHS. At present, there are no MPHSs operating under this model in Queensland.
Quilpie MPHS is currently being established. The high care places will be provided in the hospital and low care places will be provided in cottages owned by the Quilpie Shire Council. Quilpie Shire Council is not pooling their resources into the MPHS. The local advisory group includes all health providers, including Queensland Health and local government. The HACC funded organisation in Quilpie is not currently pooling funds into the MPHS, although it is anticipated that the MPHS may purchase additional services from the HACC organisation in the future.
(iv) Separate management and funding structures with input from a local advisory group
The MPHS program seeks to achieve flexibility and integration in the delivery of a range of services. This option could in many ways mitigate against the aims of the program as funding and management structures would remain separate for each service component. This approach could limit the flexibility potential of the MPHS model in terms of improving access to a range of services for people living in rural and remote communities. There are no current examples of this approach in MPHSs in Queensland. An example of such a model would be where a Queensland Health facility developed partnerships with other providers, although funding and management structures would remain separate.
5 Flexible Service Delivery Arrangements
The MPHS model attempts to develop a mix of health and community services to suit the particular needs of small communities through flexibility in the funding and management of service delivery.
The advantage of the MPHS model lies in the potential to increase the level of cooperation and integration of health and community services. For example, a MPHS can include acute hospital services as well as community based health services, and staff may work across different services. Awards currently enable all disciplines, other than nursing, to work across service settings within Queensland Health. Negotiations are currently underway with the Queensland Nurses Union to amalgamate the two separate nursing awards to allow greater flexibility in working arrangements.
6 Quality assurance
The various services which form part of a MPHS are at present subject to different quality assurance systems. For acute public hospitals, the Australian Council on Health Care Standards is the main accreditation body which sets the standards facilities must meet to achieve accreditation. For acute and community health services, the Quality Improvement Council Standards administered by the Institute of Healthy Communities applies. Residential aged care services, where they form part of a MPHS (and are designated beds located in small rural hospitals), are currently not required to meet the Aged Care Accreditation Standards set by the Commonwealth Department of Health and Aged Care.
The Commonwealth Department of Health and Aged Care has engaged a consultant to examine options for appropriate quality assurance systems to apply to MPHSs. The consultant has visited one MPHS in every State and Territory in the process of identifying what these options might be. Queensland Health has indicated to the Commonwealth that any options being canvassed would need to be considered for suitability in terms of how they might apply to Queensland Health services and facilities. Queensland Health will have an opportunity to comment on the consultant’s findings when these are made available.
7 Funding
Funds Pooling
The Commonwealth Department of Health and Aged Care in the document ‘Policy Framework: Commonwealth Regional Health Services Program’, refers to funds pooling as integral to the MPHS and RHS models.
It is suggested however, that there needs to be flexibility in terms of the funding arrangements for MPHSs to allow funds pooling to be considered as one of a number of options for facilitating service integration. Queensland Health has communicated this view to the State Office of the Commonwealth.
In the past, funds pooling has been attempted as part of the coordinated care trials. However, some trials found a strong reluctance particularly by non-government organisations to agree to contribute their funding to a central pool for fear of jeopardising the level of funds allocated to individual services participating in a trial. In Queensland, the coordinated care trial conducted in North Brisbane did not require non-government organisations to funds pool.
It is possible to achieve improved integration and coordination of services without funds pooling. Where funds are not pooled for a MPHS, the key to success lies in the management structures established and the level of cooperation and collaboration between service providers.
The issue of whether a particular MPHS will include funds pooling is a matter to be determined in the planning process undertaken to determine service needs and must be agreed between service providers.
Where a particular MPHS seeks to implement funds pooling and Queensland Health services or facilities are included, then Queensland Health has taken the view that it will seek to be the auspicing body for the service as a whole.
Cashing out: MBS/PBS
In many rural and many remote communities in Queensland, residents do not have access to the same level of benefits in terms of access to bulk billing General Practitioner services or to subsidised pharmaceuticals. This is particularly the case for Indigenous communities in the north of the State.
A study conducted by the Australian Institute of Health and Welfare in 1995/96 showed that Indigenous people benefited very little from such mainstream services as the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). The study found that Indigenous Australians used MBS at only one quarter of the rate of other Australians, yet their health needs are approximately three times higher. Per person, their benefits under Medicare were only 27 per cent of the average for non-Indigenous people and further, the proportion was only 22 per cent for prescribed drugs. It is estimated that Indigenous people receive about $100 less per person than other Australians from the MBS and PBS alone.
Queensland has historically experienced a shortfall in its share of the national MBS and PBS benefits because in rural and remote areas there are fewer private services and because Queensland Health is supplying and funding a substitute service in a number of areas. In particular, the lack of access to, and utilisation of, the MBS/PBS benefits for pharmaceuticals and primary health care services by Indigenous people in Queensland has resulted in a cost shift to the State which provides these services free of charge through the public hospital system. At the present time, the Commonwealth is making savings of around $25 million per year on MBS services that are provided and funded by Queensland Health but which should be funded by the Commonwealth, given around 1.1 million services at an average MBS benefit paid in Queensland of $23 per service.
Given the general paucity of health services available to Indigenous communities in remote parts of Queensland, the level of under-expenditure of MBS is more marked than for non-rural and remote populations.
There is potential under the MPHS program to negotiate with the Commonwealth Department of Health and Aged Care to ‘cash out’ MBS and PBS Funds to the national average for these communities.
Under this arrangement, the Commonwealth would provide funding to Queensland Health to bring the level of benefits from MBS and PBS to the national average and these funds could be used to provide enhanced primary care services to rural and remote communities across the State. In addition, the Department of Health and Aged Care now offer to make special arrangements for funding the supply of pharmaceuticals to remote area Aboriginal health services across Australia. Under these arrangements, pharmaceuticals listed on the PBS will be supplied free of charge to the remote area Aboriginal health services, and the supplying pharmacy will claim reimbursement from the Health Insurance Commission. Queensland is currently considering implementing this arrangement under Section 100 of the National Health Act.
8 Fees and Charges
The issue of fees and charges being levied by MPHSs and Regional Health Services was raised at the National Rural Health Policy Forum in December 1999. The Commonwealth subsequently drafted a paper which is yet to be formally considered by the Rural Health Policy Forum, which proposes that for residential aged care services offered as part of a MPHS, that Daily Care Fees, Accommodation Charges and Accommodation Bonds could be charged.
The Commonwealth Aged Care Act 1997 provides for flexible care services to charge accommodation payments in accordance with the User Rights Principles. Fees charged by residential aged care facilities include:
• Daily care fees. Daily care fees go towards the cost of living expenses, including meals and refreshments, laundry, heating/cooling, and nursing and personal care.
• Accommodation Charges. An accommodation charge is an additional daily fee that can be charged to high care residents for no more than 5 years while the resident is in care (only applies to private facilities, not State Government owned nursing homes).
• Accommodation bonds (only applies to private facilities, not State Government owned nursing homes). An accommodation bond is an amount that can be charged to low care residents when they enter low level care.
The Queensland Government decided in 1998 not to charge accommodation fees in State Government Nursing Homes. This position is unlikely to change in the foreseeable future.
9 Queensland Health Assets
Where physical assets owned by Queensland Health are utilised as part of a MPHS, ownership of these assets cannot be devolved to any other party. Queensland Health assets will remain as State owned.
10 Evaluation
The need for an appropriate evaluation strategy for the Regional Health Services Program has been discussed at the February 2000 meeting of the National Rural Health Policy Forum. At this meeting, the Commonwealth tabled a short paper on evaluation for RHSs, and the group agreed that a steering committee would be established to consider the issues raised in the paper further and to develop a fuller paper for later consideration by the Forum.
The Commonwealth paper on evaluation identified four components to be incorporated into a national RHS evaluation strategy, including:
1 A review of current activity (ie. existing MPS and MPC) to determine the strengths and weaknesses of existing integrated care models in small rural communities.
2 Ongoing regular performance monitoring as part of standard accountability arrangements through service agreements.
3 Overall program evaluation to determine the impact and outcomes of the program.
4 Individual service evaluations at the end or at appropriate intervals within the contract period (dependent on the nature of the service/project) to determine the effectiveness of each service and contribute to the overall program evaluation.
The Commonwealth propose to engage a consultant to undertake components 1 and 3 of the evaluation strategy. Queensland Health, through representation on the National Rural Health Policy Forum, will have the opportunity to have input into the process of developing an appropriate evaluation model applicable to MPHSs and RHSs in Queensland.
Questions for Discussion:
This discussion paper is intended to provide a basis for discussion and feedback in terms of Queensland Health’s policy position on MPHSs. The following questions refer to the key issues discussed in this paper. You may wish to respond to each of these questions, as well as raise any other issues in your feedback to the Office of Rural Health.
1 Do you think the draft principles are appropriate for the Queensland Health MPHS Program? If no, how might they be changed?
2 What are your views on the potential whole of government scope of services to be provided as part of a MPHS?
3 Do you support the rapid needs assessment planning process currently used for identified MPHSs? If no, then what alternative approach/es would you recommend?
4 Which of the approaches identified in this discussion paper should be adopted by Queensland Health to service integration for MPHSs?
5 What are the key components required for a quality assurance framework for MPHSs?
Where to Send Your Comments and Feedback
Your views are important. Please provide your comments and feedback in writing, either electronically via email (on groupwise for Queensland Health staff or Julie_Dawson@health.qld.gov.au for external stakeholders) or in hard copy to the following address:
Ms J Dawson
Principal Project Officer
Office of Rural Health
Floor 5
Queensland Health Building
147-163 Charlotte St
BRISBANE 4001
Please ensure that your comments are received at the above address by close of business on 13 October 2000.
Established Multipurpose Health Services (and funded):
Cooktown
Clermont
Quilpie
Munduberra
Dirranbandi
Regional Health Services (Funded in 2000/2001):
Texas
Inglewood
Mossman
Western Queensland (public health services)
List of locations to be developed as Regional Health Services:
Blackall*
Woorabinda*
Palm Island
Taroom*
Springsure*
Alpha*
Cloncurry
Collinsville*
Barcaldine*
Mornington Island
Doomadgee
Tambo
Agnes Waters
Aramac*
Theodore*
*Note: Queensland Health has received Commonwealth funding to undertake planning
in each of these communities
This page last updated:14 January, 2003
Review date: 14 June 2003