Health Priorities

Transcription

1 ` Health Priorities Policy and Planning Branch December 2013

2 Health Priorities December 2013 Published by the State of Queensland d (Queensland Health), Decemberr ii- This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3..0/au State of Queensland (Queensland Health) 2013 You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health). For more information contact: Policy and Planning Branch/System Policy and Performance e Division, Departmentt of Health, GPO Box 48, Brisbane QLD 4001, HSRAM@health.qld.gov.au, phone An electronic version of this documentt is available at //qheps.health.qld.gov.au/ppb/html/ppb_plan_guidelines_home.htmm Disclaimer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, s representations or warranties about the accuracy, completeness or reliability of any information containedd in this publication. The State of Queensland disclaims all responsibility andd all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information. Health Priorities

3 Contents Purpose... 1 Scope... 1 Context... 1 Commonwealth... 1 Queensland... 2 Population directions... 3 Population projections Queensland... 3 Population projections Aboriginal and Torres Strait Islanders... 4 Burden of disease Queensland... 4 Burden of disease Aboriginal and Torres Strait Islanders... 7 Burden of disease Rural and remote areas... 7 Potentially preventable hospitalisations... 8 Estimated future activity... 8 Preventative, primary and community care... 8 Outpatients... 9 Emergency care... 9 Interventions and procedures... 9 Inpatients... 9 Qualified neonates Mental health Sub and non-acute Constraints What does this mean? What can be done? Balancing the system Preventative, primary and community care Oral health Outpatients Emergency care Interventions and procedures Inpatients Qualified neonates Mental health Sub and non-acute Clinical and support services Workforce Technology Disinvestment Teaching, training and research Expected outcomes from priorities for investment Health Priorities iii -

4 Priorities for investment Health services focused on patients and people Empowering the community and our health workforce Providing Queenslanders with value in health services Investing, innovating and planning for the future Current performance in priority areas Appendixes Appendix 1 Population projections Queensland Appendix 2 Population projections Queensland Aboriginal and Torres Strait Islander people Appendix 3 Priorities for investment - Mapped to expected outcomes Appendix 4 Priorities for investment - Measures References Figures Figure 1 Figure 2 Figure 3 Relationship between Australian and Queensland Governments Strategies... 2 Age standardised rate of premature death (YLL) and disability (YLD) per 1,000 due to leading broad cause groups, 2007 and 2016 projection Burden of disease and injury due to major risk factors, by sex, percentage, Queensland, Tables Table A1.1: Estimated resident population (2012) by Hospital and Health Service Table A1.2: Estimated resident population (2011) and projected populations by Hospital and Health Service, 2016 to Table A1.3 - Estimated resident populations of Queensland by Hospital and Health Service and age groups, 30 June Table A2.1: 2011 Estimated Resident Population by age, sex and Indigenous status Table A2.2: Indigenous population change: 2006 projected to Table A3.1: Mapping of priorities for investment with expected outcomes Table A4.1: Measures associated with priorities for investment Table A4.2: Public hospital self sufficiency by HHS of residence, all ages, Table A4.3: Public hospital self sufficiency by HHS of residence, Adult (15 years+), Table A4.4: Public hospital self sufficiency by HHS of residence, Child (0-14 years), Table A4.5: CSCF version 3.1- Self-assessment HHS Service Agreement Table A4.6: KPI 1.7 Tier 1 Activity YTD end September Table A4.7: Closing the Gap obligations HHSs Performance Reporting Health Priorities iv -

5 Purpose This paper identifies short term service delivery priorities for the health system (to ) with a specific focus on informing decisions related to healthcare purchasing for the financial year. The paper will be updated annually to inform each healthcare purchasing cycle. Scope The paper encompasses all health services funded and/or provided by the Queensland public health system across the care continuum. It is acknowledged that health service delivery and management will continue to change over time, in accordance with the requirements of Council of Australian Government (COAG) Agreements relating to the national health reform program. Context Commonwealth The National Health Reform Agreement (NHRA) commits the Australian Government and all state and territory governments to work in partnership to implement new arrangements for a nationally unified and locally controlled health system. [1] The Australian Government develops a range of frameworks, strategies and plans to guide the services provided by states and territories. It also develops, in consultation with the states and territories, National health priority areas. These areas are chosen for focused attention because they contribute significantly to the burden of illness and injury in the Australian community. [2] There are currently nine national health priority areas cancer control cardiovascular health injury prevention and control mental health diabetes mellitus arthritis and musculoskeletal conditions obesity dementia asthma Under the National Health Care Agreement 2012, States and Territories are primarily responsible for the provision of health and emergency services through the public hospital system, as well as having joint funding responsibility with the Commonwealth for public health activities, mental health, sub-acute, Aboriginal and Torres Strait Islander health, research, workforce training, emergency responses and blood and blood products. [3] Community health is identified as the responsibility of State Governments, however the scope of activity defined under community health is determined by the states. An area of priority for the Australian Government is public access to emergency departments, elective surgery and sub-acute services. This is articulated through the National Partnership Agreement (NPA) on Improving Public Hospital Services which Health Priorities

6 includes the National Emergency Access Target (NEAT) and the National Elective Surgery Target (NEST). [4] Services for adults in the public dental system will be extended from 1 July 2014 in the NPA for Adult Dental Services. This NPA builds on the NPA for Treating More Public Dental patients, which focused on treating adults on public dental waiting lists. Queensland The relationship between the Australian and Queensland Governments strategies is shown in Figure 1. Figure 1 - Relationship between Australian and Queensland Governments Strategies The Commission of Audit Report was released in April 2013, along with the Government s response, A Plan Better services for Queenslanders (the plan) which accepts most of the recommendations from the Independent Commission, focussing on changes to the way the public service is structured, organised and managed to be more flexible, responsive and efficient in supporting service delivery. [5] In the Blueprint for better healthcare in Queensland [6] (the blueprint) the Minister for Health has presented a vision for healthcare in Queensland focused on four principal themes: Health services focused on patients and people Empowering the community and our health workforce Providing Queenslanders with value in health services Investing, innovating and planning for the future. The Department of Health Strategic Plan (2013 update) [7] (the strategic plan) outlines the Department of Health's (the department) strategies for supporting the achievement of the government's objectives, and the themes in the blueprint. Health Priorities

7 The objectives of the strategic plan are: healthy Queenslanders accessible services safe services value for money governance and innovation partnerships and engagement. Each HHS has a strategic plan. These plans align with the blueprint and outline strategic priorities. The above documents all recognise that to achieve better healthcare outcomes there must be a strong focus on the patient. Emphasis on good outcomes, access aligned with need, safe services, value-adding in public-private partnerships and strong governance encouraging innovation are key themes. [6] Statewide frameworks, strategies and plans ensure alignment of services with Queensland Government policies and priorities. These plans provide long-term direction to ensure the programs and services they refer to are appropriate for our rapidly changing environment. The purchasing process also considers Government priorities and decisions are made in line with these. In addition, the balance of investment across the system is considered. For the purchasing process total spend on health service delivery in was $10.1 billion. Of that approximately $7.0 billion was for Activity Based Funding (ABF) activity and $3.1 billion was for non ABF activity. Investment in ABF was targeted at service streams where a lower proportion of estimated future need had been purchased in Population directions Health and well-being challenges faced by Queensland include an ageing population, high levels of chronic disease, health-related risk behaviours and poorer health outcomes for the Aboriginal and Torres Strait Islander population. People from non- English speaking backgrounds are a growing population group having specific health needs. The Department of Aboriginal and Torres Strait Islander and Multicultural Affairs has reported that at the time of the 2011 census, 9.5 per cent of the total Queensland population came from non-english speaking households. Population projections Queensland As at June 2011, the estimated resident population of Queensland was 4.47 million people. [8]. In the five years to 2016, the Queensland population is projected to grow by 13.8 per cent to 5.09 million people. This equates to a change of 2.7 per cent per annum, which is approximately 107,000 people per year. [9] While the population will grow, the age structure will change. People in the older age groups will make up a greater proportion of the population in 2016 than in 2011, with the proportion of those aged 65 to 84 years increasing from 11.4 per cent in 2011 to 12.9 per cent in 2016 and those aged 85 years and over increasing from 1.6 per cent to 2 per cent. Appendix 1 details the population projections for Queensland by HHS from Table 1 below shows the HHS with the highest projected population growth by number and percentage from 2011 to [10] Health Priorities

8 Table 1 - Hospital and Health Services (HHS) with the highest projected population growth by number and percentage from 2011 to HHS with the highest projected population growth in the years 2011 to 2016 Gold Coast HHS: increase of 100,828 to 628,210 people Metro South HHS: increase of 93,796 to 1,126,304 people HHS with the highest projected population growth percentage in the years 2011 to 2016 West Moreton HHS: increase of 25.2 per cent to 304,459 people Mackay HHS: increase of 21 per cent to 207,229 people Metro North HHS: increase of 69,618 to 958,455 people Gold Coast HHS: increase 19.1 per cent to 628,210 people Source. InfoBank, 2012 Population growth is derived from three components net overseas migration, net interstate migration and natural increase. The volatility of historical growth rates in recent years creates uncertainty in population projection and therefore projections should be viewed with caution. New population projections, based on the 2011 census data, are due for release later this year. Looking longer term than 2016, it is projected that in the 10 years from 2011 to 2021: the concentration of population in South East Queensland will continue, albeit at a slower pace larger regional cities and centres, e.g. Toowoomba, Cairns, Mackay, Rockhampton and Hervey Bay, will attract population as a result of lifestyle and employment opportunities ongoing resource sector activity will temporarily impact upon the populations of the Darling Downs, South West, Mackay, North West and Central West HHS, through to approximately 2019 Ipswich regional council area will have the fastest percentage growth rate (five per cent) followed by Scenic Rim, Gladstone and Isaac regional council areas Gold Coast regional council area is projected to have the highest absolute population growth. [10] Population projections Aboriginal and Torres Strait Islanders In 2011 the estimated resident population for Aboriginal and Torres Strait Islander population in Queensland was 164,889 (3.7 per cent). Population projections from the Australian Bureau of Statistics suggest continued growth in the Aboriginal and Torres Strait Islander population in Queensland with estimates for 2016 of 187,449 (3.7 per cent of the projected total Queensland population), increasing to 212,908 in 2021 (3.8 per cent of the projected total Queensland population). [11] Please see Appendix 2 for more detailed information about the Aboriginal and Torres Strait Islander population in Queensland. Burden of disease Queensland Burden of disease is a measure of population health that aims to quantify the gap between the ideal of living to old age in good health, and the current situation where healthy life is shortened by illness, injury, disability and premature death. Health Priorities

9 The most recent assessment of burden of disease and injuryy in Queensland was released in 2010, utilising data available from 2007 unless stated otherwise. [12] Key findings include: Life expectancy at birth in for females was years and for males was 79.4 years. [13] Health adjusted life expectancyy (HALE) in 2006 for females wass 75.7 years and for males 71.0 years. Disability-adjusted life years (DALYs) quantify both premature p mortality (years of life lost YLLs) and years lived with disability (YLDs) within a population. The vast majority off burden is caused by non-communicable diseases (88. 1 per cent), 7. 1 per cent by injuries and 4.8 per cent by communicable, maternal neonatal and nutritional conditions. The top five causess of DALYs were: - coronary heart diseasee (9.2 per cent) - type 2 diabetes (5.4 per cent) - anxiety and depressionn (5.0 per cent) - lung cancer (4.2 per cent) - adult-onset hearing losss (4.0 per cent). The leading cause of premature death (YLL) was cancer (24.3 per cent) (Figure 2). When considering individual conditions, the top five causes of YLL weree coronary heart disease (15.4 per cent), lung cancer (8.0( per cent), suicide and self-inflicted injuries (5.8 per cent), stroke (4.8 per cent) and colorectal cancer (3.8 per cent). The top five causess of years lived with disability (YLDs) were anxiety and depression (9.8 perr cent), typee 2 diabetes (8.7 per cent), adult-onset hearing loss (7.8 per cent), dementia (3.8 per cent) and asthma (3.8 perr cent) (Figure 2). An estimated 31 per cent of thee burden of disease was due to the joint effect of 13 modifiable risk factors. f Thee leading risk factor was excess weight (highh body mass) (8.5 per cent), followed by tobacco (7.2 per p cent) and physical inactivity (6.4 per cent) (Figuree 3). - The impact of food andd nutrition is not fully assessed, with analysis indicating 16 per cent of the burden was due to the joint effect of high body mass, high cholesterol, high blood pressure, low fruit and vegetable consumptionn and physical inactivity. Figure 2 - Age standardisedd rate of premature death (YLL) and disability (YLD) per 1,000 due to leading broad cause groups, 2007 and 2016 projection Source: Queensland Burden of Disease and Injury, Series 2, circular 7, December Health Priorities

10 Figure 3 - Burden of disease and injury due to major risk factors, by sex, percentage, Queensland, 2007 Percentage Males Females High body mass Tobacco Physical inactivity High blood pressure High blood cholesterol Net alcohol Low fruit and vegetable intake Occupational exposures Illicit drugs Intimate partner violence* Child sexual abuse Air pollution - long term Unsafe sex *assessed for females only Source: The Health of Queenslanders: fourth report of the Chief Health officer, Queensland, 2012 Four main trends will drive change in the leading causes of DALYs. These are: - ageing populations - increases in non-communicable diseases - shifts toward disabling causes and away from fatal causes - changes in risk factors, particularly the influence of obesity. The burden rate is projected to decrease by 8.1 per cent between 2007 and 2016 (Figure 2). [14] However, due to population growth and ageing the total burden of disease and injury (that is DALYs, not DALY rates) in Queensland is projected to increase by 19 per cent. Cancer, nervous system and sense organ disorders (such as dementia, Parkinson s disease, macular degeneration and adult onset hearing loss), and diabetes (including complications from diabetes such as renal failure) are the largest contributors to the projected increase in burden. Cancers are projected to remain the leading broad cause group, with nervous system and sense organ disorders overtaking cardiovascular disease to become the second leading broad cause group in The rate of diabetes burden is projected to increase by 17.3 per cent, greater than for any other broad cause. The greatest improvement in rate of burden is projected to be for cardiovascular disease, which is estimated to decrease by 26.4 per cent. Overall, the rate of YLL is projected to decrease by almost one-fifth over the 10-year period. However, the actual number of YLL is expected to increase by 10 per cent. Although the fatal burden rate from cancer is projected to decrease 12.4 per cent by 2016, cancer will remain the leading cause of YLL between 2007 and The non-fatal (YLD) burden rate is projected to increase by 1.1 per cent between 2007 and 2016, while for years lost due to non-fatal outcomes the projected increase is 27 per cent. The three leading broad cause groups associated with the increase are nervous system and sense organ disorders (15.5 per cent), diabetes (12.0 per cent) and cancer (8.4 per cent). Health Priorities

11 Burden of disease Aboriginal and Torres Strait Islanders In Queensland, the life expectancy gap between Indigenous and non-indigenous Queenslanders is 10.4 years for males and 8.9 years for females. The Indigenous child mortality rate is twice the non-indigenous child mortality rate. [15] Data from indicates significant improvements in adult mortality rates (circulatory disease and avoidable mortality), and infant mortality rates. However rates of diabetes, end stage renal disease, obesity and substance use remain significantly higher than that of non-indigenous Queenslanders. Therefore, improving early detection, management and treatment of preventable conditions will make a significant difference to Aboriginal and Torres Strait Island health outcomes. [16] In 2007, the Aboriginal and Torres Strait Islander population of Queensland made up 3.6 per cent of the total Queensland population, but despite its much younger age structure, carried 4.6 per cent of the total Queensland disease burden. [17] The health status of Aboriginal and Torres Strait Islander people is impacted by risk factors, such as poor diet, physical inactivity and smoking. It is also impacted by socio-economic and environmental factors, and the availability and quality of health services provided. Mental disorders and cardiovascular disease were the leading contributors to the burden in Aboriginal and Torres Strait Islander Queenslanders in 2007 accounting for 32 per cent of the total burden, followed by diabetes mellitus, chronic respiratory disease and malignant neoplasms accounting for 27.6 per cent of the total burden. Cancer contributed 8.5 per cent of the burden for Queensland s Indigenous population. Health Gap The health gap is greatest for Aboriginal and Torres Strait Islander Queenslanders living in remote and very remote areas. [17] However, this represents only 20 per cent of the Indigenous population and consequently the illness experienced by those living in regional and urban areas contributes most to the quantum of the burden. Health Adjusted Life Expectancy In 2007 the gap in HALE between the Indigenous Queensland population and the total Queensland population was approximately 12.3 years. [17] There was significant variation in the HALE by remoteness, with the gap in HALE between Indigenous Queenslanders in major cities falling to 8.2 years, but increasing to 15.7 years in remote areas. The largest contributor to the gap in HALE between Indigenous Queenslanders and the total Queensland population was cardiovascular disease, which contributed 2.4 years to the gap for major cities and up to 4.1 years to the gap in remote areas. This was followed by diabetes, chronic respiratory disease, and cancer. However there was some significant regional variation, with intentional injuries and infectious disease ranking in the top five for remote areas. Burden of disease Rural and remote areas Whilst there are well known challenges for Aboriginal and Torres Strait Islander people living in rural and remote areas, there are also significant challenges for the non- Indigenous population. In a study undertaken in 2008, remote areas had a disproportionately higher rate of burden of disease than major cities 1.5 times higher. The largest rate difference between regions was for intentional and unintentional injuries and diabetes, with rates in remote areas 2.6 times higher than major cities. [18] Health Priorities

12 Potentially preventable hospitalisations In , there were 141,964 potentially preventable hospitalisations (PPH) in Queensland. Fifty per cent of these hospitalisations were for acute conditions, 47 per cent for chronic conditions and three per cent for vaccine preventable conditions. Queensland had the second highest PPH separation rate per 1000 population for vaccine preventable conditions (behind Northern Territory) and the third highest PPH separation rate per 1000 population for acute and chronic conditions (behind Northern Territory and Western Australia). When excluding diabetes from chronic conditions, Queensland had the second highest PPH separation rate per 1000 population for chronic conditions. The five conditions with the highest number of potentially preventable hospitalisations were: diabetes complications chronic obstructive pulmonary disease dehydration and gastroenteritis pyelonephritis dental conditions. [19] In the period to the PPH rate in remote and very remote areas was more than twice that of major cities. The rates in Cape York, Torres Strait and Northern Peninsula and North West HHS were highest of all HHS and at least double the Queensland rate. [20] Estimated future activity Estimations of future health service activity are used to gain an understanding of the potential future health service delivery environment. They incorporate a range of factors including burden of disease information and projected population growth. A number of methodologies are used to develop the estimates, depending on the service stream. More information regarding the methodologies is available at (internal The department access only): [21] Initial estimates of future activity for are based on existing service patterns. These are presented below and provide some indication of future activity. In some instances both large numerical changes in activity and large proportional changes are presented. It is appropriate that both types of changes are considered in determining future priorities for service provision. Only proportional shifts that are considered significant are discussed. Preventative, primary and community care While there are some central data systems for preventative and primary care provided by the State (such as dental, breast and cervical screening), these are not available for all services. As such, estimating future activity for all service types with any certainty is not possible. However, given the burden of disease information which indicates high prevalence of modifiable risk factors and the leading causes of disability burden as musculoskeletal and mental health, it can be assumed that requirements for preventative and primary health care will increase in the future. Health Priorities

13 Some data on primary and community care services, which are provided in an outpatient setting, are included in the analysis below. Outpatients In recent years, outpatient occasions of service (OOS) have increased at a rate greater than population growth. In addition, Outpatient Services waiting list data for the period April to June 2013 indicates that there are approximately 216,000 patients waiting for an initial specialist outpatient consultation. All clinical specialities have a percentage of their waitlist that are waiting for appointments longer than is considered clinically appropriate. The specialties with the highest number of patients waiting longer than clinically recommended are neurosurgery (79 per cent), rheumatology (78 per cent) and pain management (69 per cent). [22] Given historical trends and the large waiting list for outpatients, it can be assumed that demand for these services will continue to increase at a rate higher than projected population growth to Emergency care Presentations to Emergency Departments are estimated to increase by more than 20 per cent from to The majority of the increase is projected to occur in triage category 3; however there will be larger proportional increases in triage categories 1 and 2. Interventions and procedures Large volume increases are expected in OOS for radiation oncology and renal dialysis between and (in excess of 90,000 for each). Large proportional changes are expected in Interventional Cardiology and Endoscopy (50 per cent or more). Inpatients In the Queensland public sector between and , inpatient activity is expected to increase by 22 per cent. Adult separations are projected to increase by 24 per cent, whereas separations for children (0 14 years) are expected to increase by ten per cent. Based on current flow patterns, just over 40 per cent of projected activity for children is expected to occur at specialist children s hospitals in Brisbane. High volume increases in activity for adults (more than 5,000 separations) are expected to occur in the following Enhanced Service Related Groups (ESRGs): some general medicine including venous thrombosis, hypertension, febrile convulsions, allergic reactions and congenital anomalies and problems arising from the neonatal period chest pain digestive system diagnoses including gastro-intestinal obstruction respiratory infections/inflammation. Health Priorities

14 Other ESRGs in which high proportional increases in adult activity (40 per cent or more) are expected include: delirium renal failure dementia cystourethroscopy kidney and urinary tract infections. High volume increases in activity for children (more than 400 separations) are expected to occur in the following ESRGs: other respiratory medicine some general medicine (as above) tonsillectomy or adenoidectomy whooping cough and acute bronchiolitis respiratory infections/inflammations dental extractions and restorations. Based on current patient flows, 32 per cent of the increase in these ESRGs is expected to be accommodated at the Queensland Children s Hospital, but only ten per cent of the increase will be generated by children residing within the facility s local catchment. It should be noted that these projections are based on historical supply and, as such, do not take into account current waiting lists. As at June 2013, there were 36,188 people waiting for elective surgery in Queensland. Eighteen per cent of those patients (6,442 patients) were waiting longer than the clinically recommended time. Of this group, neurosurgery (44 per cent), plastic and reconstructive surgery (28 per cent) and orthopaedic surgery (24 per cent) had the highest proportion of patients waiting longer than clinically recommended. [23] Qualified neonates There are expected to be large proportional increases in both neonatal intensive care nursery and special care nursery bed days to (in excess of 45 per cent). Mental health Between and , large increases (more than 40 per cent) are expected in both acute and sub/non-acute mental health bed days, with sub/non-acute bed days expected to have a higher increase than acute. Sub and non-acute Estimated future activity for Rehabilitation and Geriatric Evaluation and Management (GEM) suggests large volume bed day increases to (in excess of 35,000 bed days). Large proportional increases are expected in Palliative Care and GEM bed days (close to 40 per cent). Health Priorities

15 Constraints The following constraints may impact on the sector s ability to achieve its objectives: Communities and clinicians understanding and expectations of how services are delivered and the time it takes to change. Historical service delivery models may be a constraint to the development and adoption of new models of care. Suboptimal uptake of alternative models of care: e.g. telehealth, multidisciplinary case management teams. Funding models which may not support alternative service provision, for example, an absence of payments for asynchronous service delivery via both ABF and Medicare Benefits Schedule (MBS). Workforce shortages and inflexible professional roles: workforce issues are predominant in specific professional groups and service streams, [24] there is disparate shortage of a variety of health care positions which tends to be a particular issue in rural and remote areas, limiting the provision of both specialist services and general practice. Inflexibility across professional roles also limits the ability to fully utilise the available workforce. Health infrastructure and capacity: increased capacity in some service streams, or at some locations, and flexibility is required to meet service needs over the next three years. Unclear and finite financial resources: ongoing negotiations around the Australian Government's proportional contribution to the total amount the department spends on health, as per the NHRA, will impact on priority setting until resolution and there is a clearer understanding of available resources, furthermore, finite resources are a reality in the face of ever growing demand for public health services. Slow progress on change: the current attempts to change the way business is done can be constrained by issues related to privacy, security and trust, particularly with regard to technological advances such as electronic medical records which are currently being implemented in some HHS. Changes to established cultures and practices that impacts on performance are needed and slow progress in this area will have an impact on performance and regaining community confidence in the health system. [14] Information and communication technology: the development and implementation of statewide information management systems and centralised data collections for some service streams is slow and hinders statewide reporting of outcomes, quality and activity. Lack of appropriate data-capture systems and processes to collect information regarding community health/non ABF activities. This information would allow ongoing assessment of changes in use and consideration of community health priority needs, as well as safety and quality improvement monitoring. Different strategic approaches between the department and the HHS. Health Priorities

16 What does this mean? The epidemiological data shows projected increase in the burden of disease in the areas of cancer, nervous system and sense disorders and diabetes. The increase in nervous system and sense organ disorders is primarily due to the ageing population and the increased prevalence of these diseases, such as dementia, in older age groups. [14] The increase in diabetes includes the impact not only of diabetes itself, but also of complications associated with diabetes, such as renal failure and peripheral vascular disease. The current risk factor profile does not suggest there will be significant change in the contributors to the burden of disease. The data on potentially preventable hospitalisations substantiates the epidemiological data, with Queensland having high rates of potentially preventable hospitalisations compared with other states, particularly for chronic conditions. The estimated future activity supports these observations, with large increases expected in the treatment of cancer and renal disorders and conditions associated with ageing. The impact of the national bowel screening program is also being seen with projected increases in endoscopy and follow-on surgery to address findings. It is universally agreed that such increases in demand are unsustainable and that business as usual is not an option for the health system. Changes are required across the care continuum in order for the system to effectively manage future demand. What can be done? Balancing the system Health services should be distributed across the state in relation to both geographic location and the different types of services provided (service streams) based on community need. Sufficient services need to be purchased in each part of the care continuum to allow patients to flow through the various service streams in order for the health system to work effectively and efficiently. For example, enough sub-acute services need to be purchased to allow patients to flow through from acute care settings otherwise bed block will occur in the acute setting. Preventative, primary and community care Preventive health action aims to support good health and eliminate or reduce those factors that contribute to poor health. While it focuses primarily on people who are currently in good health, and those who are at risk of illness, it is also concerned with preventing, where possible, the progression of disease among people already affected (secondary prevention). [25] Preventative and primary health In order to bend the health care cost curve and have any lasting effect on health system demand, risk factors prevalent in the at risk population need to be targeted. Evidence indicates that addressing risk factors for chronic disease is critical in improving long-term health outcomes and reducing the impact on the public health system. There is a need to address unhealthy environments and cultures as well as individual behaviours. There are campaigns already in place to promote awareness of the harm of smoking and the need for physical activity and good nutrition. Sustained and expanded activity is required in health promotion in the areas of obesity, smoking, Health Priorities

17 alcohol and sun safety to reduce risk factor levels in the population and reinforce positive health messages for good health and well-being. The challenges of accessing and delivering health services in rural and remote areas of Queensland are well known. There may be more gains achieved by investing in targeted health promotion and prevention activities and in primary and community care in order to prevent potential hospital presentations in the future. In some cases partnerships across organisations, communities and individuals have already been established. [26] While primary health care is the responsibility of the Australian Government, and public health activities are funded jointly by the Australian and state and territory governments, the individual states and territories are responsible for community health. Queensland public health service providers (HHS) must work in partnership with Medicare Locals (MLs) and other providers to address health and well-being challenges faced by Queenslanders. It is expected that benefits from the partnerships will flow through to the rest of the system in the future. The resultant effect could be: avoidance of unnecessary hospital admissions a reduction in the number of emergency presentations that could be managed by a general practitioner, in turn assisting in the achievement of NEAT targets the management of chronic disease in the community, working with MLs to influence increased general practitioner participation development of a standard process for referring patients to hospital specialists. Aboriginal and Torres Strait Islander people The department s strategies in Aboriginal and Torres Strait Islander health will be principally guided by the renewal of the NPA on Closing the Gap in Indigenous Health Outcomes for the period and the NPA on Indigenous Early Childhood Development Activities under these NPAs will assist Queensland in meeting the health-related Closing the Gap targets, specifically: to close the life expectancy gap within a generation (2031) to halve the gap in mortality rates for Indigenous children under five within a decade (2018). Improving health literacy Health literacy refers to the capacity to acquire, understand and use information for health. Research has identified that 40 per cent of Australians lack basic health literacy, and a person with poor health literacy will respond less to health education and is less able to manage chronic conditions such as diabetes and asthma. [27] Improving health literacy has become an empowerment strategy to increase people s control over their health, to make informed choices, reduce health risk and increase quality of life. Improved health literacy has the potential to reduce preventable hospital admissions, decrease costs and improve health care outcomes. A significant amount of work has already been done in Australia to improve health literacy. However, to date there has not been agreement about a coordinated approach. The Australian Commission on Safety and Quality in Health Care (ACSQHC) has commenced work to develop a national approach which will assist health service providers in enabling improved health literacy. [28] Health Priorities

18 Social marketing Social marketing has increased in popularity amongst public health professionals since the 1970s and is now widely accepted in Australia as an aid to minimise the health challenges faced by Australian communities. The activity is generally defined as a program-planning process that applies commercial marketing concepts and techniques to promote voluntary behaviour change. [29] Social marketing campaigns developed by the department focus on: prevention of chronic disease promoting early detection and protective health behaviour responding to public health issues or communicable disease outbreaks introduction of new legislation or government policy actions emanating from national health priorities. [30] Maximising participation in assessment and screening programs Assessment and screening programs aim to detect potential health problems before they have become apparent or before medical attention is sought, the intent being to initiate treatment at an earlier and more optimal time, so as to prevent or favourably alter their course and consequences. [31] Assessment and screening begins at birth with Newborn Screening tests for genetic and orthopaedic conditions and for hearing. Post-natal assessment is now provided through the Mums and Bubs program which provides two home visits to mothers and babies in the first four weeks of life. Ongoing assessment is provided in Child Health Clinics up to the age of approximately four years. Screening programs for adults focus mostly on cancer. These screening programs are successful for detecting breast cancers and pre-cancerous changes that can lead to cervical and bowel cancers. Early detection and treatment of cancer can reduce the burden on patients, their families and the health system. Maximising participation, support and interest in population screening programs requires that sustained information be available from multiple channels as well as the implementation of effective primary prevention strategies aimed at known modifiable risk factors. This is especially the case at a time when: the BreastScreen Australia target age range is being proposed to be expanded from women aged 50 to 59 years to women aged 50 to 74 years the National Bowel Screening Cancer Screening Program is currently being reviewed to consider including people aged by 2020 a review of the National Cervical Screening Program including age-group range, screening interval, new technologies and collaboration with the National Human Papillomavirus Vaccination (HPV) Program is underway. (While the HPV Program has shown some success in reducing HP prevalence, the vaccine is only effective against four subtypes of HP and as a result, cervical screening will remain an essential component of the health system). Funding for the bowel and cervical screening programs is provided by the Australian Government, while BreastScreen is jointly funded by the Australian and State Governments. Further investigation or treatment required as a result of screening is funded by the State (if the patient chooses to be treated publicly). The potential expansion of the bowel and breast screening programs suggests that the number of people requiring additional care in the State health system will increase. Investment will be required in the services involved in this follow-up, most notably endoscopy. Health Priorities

19 Oral health The Australian Government s recently announced Dental Reform package will improve access to dental services. The Grow Up Smiling program will commence from 1 January Under the program a Commonwealth funded capped benefit entitlement will be provided for basic dental services for children whose family meets a means test. Children will be able to access services from a public or a private dentist. The introduction of these new programs (particularly the NPA for Adult Dental Services) will result in increased identification of dental problems, resulting in increased demand for procedural dental services in public hospitals. There will be a need to work with the private sector and in some locations increase available resources, such as dental chairs and theatre capacity, to meet the demand. Outpatients The demand for public outpatient services exceeds the ability to process referrals efficiently within the recommended timeframe. Expansion in screening programs over the next three years (especially bowel screening) will increase demand further. Potential strategies to address the issues associated with lengthy waiting times and demand include: development of consistent, standardised criteria for referral and prioritisation of patients for outpatient medical specialist services increased use of mhealth in patient management, e.g. mobile phone applications for appointment reminders expansion of existing strategies aimed at reducing demand for specialist outpatient appointments e.g. orthopaedic physiotherapy screening and multidisciplinary service now implemented in 15 hospitals across the state has led to improved surgical waiting times for orthopaedic surgery centralised referral and booking processes development of criteria for discharge from ongoing patient review to enable junior staff/nursing staff to discharge patients and free up capacity for new case referrals using telehealth to provide specialist outpatient consultations to patients in rural and remote locations, incorporating a statewide centralised booking system to assist in service viability increasing volumes of outpatient activity. Emergency care Emergency departments are now committed to national performance targets to admit, transfer or discharge patients within a four-hour timeframe. Real time key performance indicator data in emergency departments will give an increased capability to monitor performance at a local level. Improved access and throughput in Emergency Departments will be required to manage increased demand. Strategies that have the potential to assist in achieving this outcome include: use of electronic medical records to give timely access to clinical information and enable secure transfer of information between the community and the HHS Health Priorities

20 integration of clinical guidelines into clinical IT systems standardisation and prioritisation of pathology and radiology ordering by junior medical officers trialling nurse practitioner and/or nurse led models/clinics as an alternative to standard models of emergency care with priority emphasis in rural and remote areas, Aboriginal and Torres Strait Islander communities and with consumers living with chronic disease supporting rural and remote locations through the use of telehealth and/or retrieval services working in partnership with Queensland Ambulance Service (QAS) to progress QAS pre-hospital initiatives. Interventions and procedures The expected large volume increase in demand for interventions and procedures will require HHS to investigate alternative ways of delivering services to patients. In particular, purchasing health activity from the private and not-for-profit sectors where that alternative service delivery can be shown to be safe and cost-effective will be important where infrastructure capacity is constrained. The expected increase in the need for cancer treatment will require expansion of radiation oncology and chemotherapy services. Technical advances in radiation oncology have resulted in the ability to treat patients using fewer fractions, thus potentially freeing up capacity in existing machines. Expansion of the use of these technologies has the potential to allow some of the increase in demand to be managed. Increased access for regional and rural patients to local chemotherapy and radiation oncology treatments will also need to be investigated through the expansion of services such as tele-chemotherapy, which is currently in use in Northern Queensland, and the establishment of new radiation oncology services (whether run by the HHS or outsourced to the private sector). There will be an increase in interventional cardiology infrastructure and services over the next three years with the establishment of additional cardiac surgery sites, cardiac catheter laboratories and a move towards the networking of services to provide 24 hour access to angioplasty services for a greater proportion of the population. There will be an increased demand for related technology, e.g. hybrid imaging systems such as positron emission tomography (PET) and magnetic resonance imaging (MRI), and various electrophysiology devices. Careful consideration and cost benefit analyses need to be undertaken prior to the introduction of these new and expensive technological advances in services and treatment. Following introduction, outcomes and standards of practice will need to be closely monitored. Inpatients Increased demand for inpatient services will place significant financial and capacity pressure on the health system. There will also be increases in the complexity of patients in the inpatient setting as a result of ageing and the corresponding increase in patients presenting with multi-morbidities. Services will need to be configured in the most efficient and effective way and current capacity in regional, rural and remote facilities will need to be utilised. As such, HHS will need to reconfigure service provision to ensure that services that can be safely provided in smaller facilities are redirected from major facilities. The reintroduction of birthing services in rural areas is one example of such a strategy, as is the provision of Health Priorities

21 non-complex children s services in regional and rural hospitals (with support from Children s Health Queensland). Effective mechanisms for consultation, referral and transfer to higher level services if required will need to be developed to ensure the safety and sustainability of these services. Models of care will also need to be developed to address emerging trends of: multi-morbidity in chronic disease multidisciplinary teams needed to stage and recommend appropriate evidence-based treatment programs, particularly in cancer care. In addition, HHS will need to ensure that services are provided in the most efficient manner, through strategies such as the development, implementation and monitoring of evidence-based standardised care pathways for appropriate conditions. Providing services in alternative settings Increased demand for inpatient services, the high costs of health delivery in this setting and constrained built infrastructure require consideration of service provision in alternative settings. Hospital in the Home (HITH) and Hospital in the Nursing Home (HINH) can result in significant cost savings, lowering the average daily treatment cost across a broad variety of conditions. Costs are influenced by the specific condition being treated and its severity, patient age and/or gender, care team composition, and the number of daily home visits. The Diabetes Services Statewide Health Service Strategy 2013 illustrates how diabetes services can be provided in the most appropriate setting by the most appropriate service delivery model for local health needs (especially in rural or remote communities), according to the stage of disease. [32] Similarly the Renal Health Services Plan promotes the shift away from inpatient activity to well-supported outpatient or self-care/home-based activity. HHS need to work towards meeting home-based targets for dialysis in order to accommodate the expected increase in demand. Qualified neonates Ongoing growing demand for neonatal services will require not only continuing support of well-established retrieval services but improvement in non-urgent transfer services returning infants from Neonatal Intensive Care units to special care units closer to home (so-called back transfers ) is key in ensuring cots are utilised efficiently. Workforce considerations will be important, including the need for additional neonatal nurses and associated training and development. Expansion of the emerging nurse practitioner programme may also assist with demand management. There are already considerations being given to standardised admission practices and changing models of care that could transfer some care items to either the post-natal area or to HITH programmes, freeing capacity to aid future demand management. Mental health The expected 40 per cent increase in non-acute beds by 2017 prompts the consideration of options for community care for people with moderate to severe mental illness. This could include service models providing greater levels of in-home support (for example through the provision of a mental health home help support worker) for those with a mental illness and their families and carers. Health Priorities