Ernst & Young undertook consultations with representatives from peak bodies and from state and territory jurisdictions. The purpose of the consultations was to assess the degree to which the National Service Improvement Framework for Heart, Stroke and Vascular Disease was understood and utilised across the system, to gain a first level understanding of programs in place and to discuss gaps or areas for greater attention moving forward.
MeetingsThe Ernst & Young team has consulted with the following key stakeholders:
- Departments of Health/Human Services in States/Territories
- The National Heart Foundation (NHF)
- The National Stroke Foundation (NSF)
- The National Aboriginal Community Controlled Health Organisation (NACCHO)
- The Australian General Practice Network (AGPN)
- The Royal Australian Colllege of General Practitioners (RACGP)
- The Australian Health Insurance Association (AHIA)
- Kidney Health Australia
- The Australian Diabetes Society
- The Baker and International Diabetes Institute (Indigenous Division)
- Australian Primary Care Collaboratives
- Australian Commission on Safety and Quality in Health Care
- National Institute of Clinical Studies
- Members of the Review Advisory Group
|Australian Capital Territory||Mr Ross O’Donoughue||Executive Director, Policy Division|
|Australian Commission on Safety and Quality in Health Care||Chris Baggoley||Chief Executive|
|Australian Diabetes Service||Dr Stephen Tick||Dr Tick spoke from his professional perspective, not on behalf of the ADS|
|Australian General Practice Network||Ms Liesel Wett||Deputy CEO|
|Australian Health Insurance Association||Dr Michael Armitage||Chief Executive Officer|
|Baker Heart and International Diabetes Institute||Dr Alex Brown||Physician, Centre for Indigenous Vascular and Diabetes Research|
|Kidney Health Australia||Assoc Prof Tim Mathew||CEO|
|NACCHO||Dr Sophie Couzos||Public Health Medical Officer|
|New South Wales Government||Ms Clare Gardiner||Area Performance Manager and Project Director, Health Service Performance Improvement Branch, NSW Health|
|Northern Territory Government||Dr Christine Connors||Head of Chronic Disease Strategy, Health Services Division|
|Queensland Government||Ms Deborah Hill|
Ms Jane Levy
|Principal Project Officer, Clinical Networks Team|
Co-ordinator, Stroke Clinical Network
|Royal Australian College of General Practice||Professor Mark Harris||Professor of General Practice, School of Public Health and Community Medicine, UNSW|
|South Australia Government||Dr David Panter||Executive Director, Statewide Service Strategy, SA Health|
|Tasmania Government||Dr Kelly Shaw||Chief Health Officer and Acting Medical Officer, DHHS|
|University of Queensland||Professor Wendy Hoy||Director, Centre for Chronic Disease|
|Victoria||Ms Kylie Mayo||Manager, Clinical Networks and Service Development, DHS|
|Western Australia||Dr Stephen Bloomer||Lead, Cardiovascular Health Network, WA Health|
WorkshopThe NHF and NSF have jointly published a document Time for Action, which contains 34 recommendations, based on the National Service Improvement Framework for Heart, Stroke and Vascular Disease for improving cardiovascular health.
On the 15th December 2008,a workshop was held in Melbourne with representatives from and clinical advisors to the NSF and the NHF. The workshop was to discuss the National Service Improvement Framework for Heart, Stroke and Vascular Disease, the recommendations contained in Time for Action and the high priority recommendations contained in a joint budget submission of the NSF and NHF to the Australian Government. With clinical and health economics input, the Ernst & Young team worked with participants to analyse and cross reference these documents with information received from jurisdictions and other stakeholders, considering evidence, relevance, equity, ease of implementation and acceptability of recommendations.
The workshop participants engaged in considerable discussion and debate about key priorities from Time for Action and the budget submission; these cover all the domains of the National Service Improvement Framework for Heart, Stroke and Vascular Disease.
During this debate it became clear that to gain maximum benefit from any future investments, there should be bundling of related recommendations into logical packages. For example, there could be real gains in bundling improvements to the absolute risk assessment process with implementation strategies for clinical guidelines in general practice. It would make sense to invest in these two key capacity building initiatives, which strengthen the system’s ability to respond effectively, prior to undertaking actions that would increase demand on the system.
Workshop participants took the concept of bundling and applied it to the priority recommendations contained in the key documents. As the workshop progressed it became clear that there were a number of frameworks on which bundling of priorities could be based. The development of an agreed framework for bundling of priorities will now continue in the development of the draft Final Report.
Some of the key areas for discussion at the workshop were:
- There may be potential to fund CVD investments through revenue gained from the ALCOPOP tax and through possible increases in taxation on tobacco to bring Australia into line with the Framework Convention on Tobacco Control (WHO). It is recognised that this is an issue that will require policy consideration by the Australian and State Governments.
- There are different standards of evidence available for different options. Some options are supported by practice but not by evidence. Where evidence is strong, this provides confidence in investment. Where evidence is patchy or weaker, this may signal the requirement for a pilot or demonstration project. Where there is no evidence this may signal an opportunity for research. Notwithstanding, evidence should not be the only lens through which the viability and desirability of options is viewed.
- Where options will require investment and action by a third party (for example, jurisdictions or general practice) the use of targeted KPI’s and performance measures was consistently raised as a means of improving adherence. National consistency in standards for CVD care was supported. The concept of stick and carrot methods to improve compliance was discussed.
- While some options can be built up from lower levels of initial investment, under-investing for other options will result in marginal improvement and is therefore a suboptimal investment. For example, the metrics for social marketing define the minimum amount that should be invested to achieve adequate coverage and influence. Detailed costing of all options will need to be undertaken as part of the process of deciding where to invest future funds.
- There are clear differences between cardiac events and stroke, particularly in the acute stages of these conditions. While recognising that many of the preventative and risk assessment options and some of the post-acute options cover CVD broadly, participants were concerned that the specific clinical interventions related to stroke and cardiac were not lost in this review.
Attendees at the workshop are listed in the table below.
|Rohan Greenland||National Heart Foundation|
|Dr Andrew Boyden||National Heart Foundation|
|Dr Erin Lalor||CEO, National Stroke Foundation|
|Prof Derek Chew||Department of Cardiovascular Medicine, Flinders Medical Centre|
|Prof Rob Carter||Chair in Health and Human Service Economics, Deakin University|
|Dr Dominique Cadilhac||Head of Public Health Division, National Stroke Research Institute|
|Jim Birch||Partner, Health and Human Services, Ernst & Young|
|Karen Edwards||Associate Director, Business Advisory Services, Ernst & Young|
|Teresa Comacchio||Consultant, Business Advisory Services, Ernst & Young|
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Summary of early consultations (for Progress Report)These consultation as well as others undertaken after development of the Progress Report have been used to inform the content of the final report.
National Stroke Foundation (NSF)NSF is the peak body in Australia for stroke, and supports specific activities to improve the identification and treatment of stroke. Ernst & Young has met with key representatives of the NSF individually and in a workshop held on the 15th December 2008. In addition Ernst & Young has considered a number of documents provided by the NSF.
National Heart Foundation (NHF)NHF is the peak body in Australia for cardiac disease. The organisation provides support for professionals in key areas such as research and the development of clinical guidelines. NHF also coordinates a range of programs to improve cardiovascular health. A long-held advocacy goal of the NHF is the establishment of a national cardiac procedures register. Ernst & Young has met with key representatives of the NHF individually and in a workshop held on the 15th December 2008. In addition Ernst & Young has considered a number of documents provided by the NHF.
Time for ActionTogether the NSF and the NHF have published Time for Action – A national plan to reduce the burden of cardiovascular disease. This document makes 34 recommendations, many of which relate directly to the critical intervention points contained in the National Service Improvement Framework for Heart, Stroke and Vascular Disease. The recommendations contained in Time for Action have been further refined into a list of 15, contained in a submission on the 2009-10 Commonwealth Budget.
These 15 recommendations were considered in a workshop with the NSF and NHDF held on the 15th December, 2008, in the context of Time for Action and information received from other peak bodies and jurisdictions.
Kidney Health AustraliaKidney Health Australia is the peak body for kidney disease in Australia. Although vascular disease is only one cause of kidney disease, this disease is grouped with other vascular diseases as a health priority covered by the National Service Improvement Framework for Heart, Stroke and Vascular Disease.
Kidney Health Australia considers that the sections in the National Service Improvement Framework for Heart, Stroke and Vascular Disease related to kidney disease remain current. Kidney disease is described by Kidney Health Australia as a “silent disease” which needs to be detected through identification of risk before symptoms become obvious. Identified risks should then translate into management strategies.
Key issues for Kidney Health Australia are:
- The perceived lack of recognition of kidney disease as separate from the bundle of CVD, which was managed by inputting kidney disease priorities into the National Service Improvement Framework for Heart, Stroke and Vascular Disease.
- The lack of implementation of the National Service Improvement Framework for Heart, Stroke and Vascular Disease
- The need to find incentives to encourage GPs to identify, assess and treat CVD, kidney disease and diabetes. The creation of an MBS item number to cover CVD screening for ages 59 – 75 was suggested.
State and Territory Health DepartmentsInitial consultations have been undertaken with most jurisdictions to assess the high level strategic directions being taken for CVD. Queensland has elected to provide written information rather than by interview.
Information regarding jurisdictions has been gathered by internet search and interview. Appendix C contains the contact details of individuals interviewed in each jurisdiction. A request for further information is being sent to the jurisdictions and this further information will be analysed and provided within the content of the draft Final Report. As information gathering from jurisdictions is still in progress, this draft Progress Report contains a summary of key themes and issues, rather than a full analysis per jurisdiction.
Generally the jurisdictions held the view that the National Service Improvement Framework for Heart, Stroke and Vascular Disease was a good document, which had not been fully implemented because it was released without accompanying mandates and resources. This view was held despite the document having been signed off by Health Ministers (with the implied commitment this suggests) at the time.
Jurisdictions are at various stages of developing and implementing strategies that relate to CVD, but within an overall chronic disease framework. Key themes that are emerging from discussion with jurisdictional representatives include:
- The benefits of national level direction in relation to building blocks such as clinical guidelines, clinical registers, clinical networking and KPI’s.
- The need to integrate and improve transitions between primary, long-term and acute care services for patients. This encompasses care planning processes but also establishment of integrated clinical information (an electronic health record).
- The need to improve “in-time” access to appropriate emergency and acute care in both rural and metropolitan settings. For example, several jurisdictions spoke of the benefits of taking ECGs in ambulance and transmitting data to emergency departments to reduce time between an event and appropriate treatment.
- Ongoing issues in achieving adherence to existing clinical guidelines within the acute and community-based settings, including emergency departments.
- The need to focus care around the patient and to understand the patient experience, for example, the ACT is working with the NHF to improve the availability of useful written information to patients who have had a cardiac event.
- The lack of information systems that enable the collection and analysis of data and support reporting on outcomes, compliance with KPI’s and clinical trends.
- The benefits of focussing on the prevention and assessment of risk for CVD. For example, the ACT is working with the local Division of General Practice and the NHF to implement Heart Moves in accredited gyms. Victoria is working with the NSF to run the FAST campaign in Victoria and reports anecdotal evidence that younger patients are presenting with symptoms of stroke because they recognise the FAST symptoms.
- Concern regarding the current capacity of general practice with regards to management of CVD. In particular, a number of jurisdictional representatives noted resource issues (scarcity of GPs) and a lack of adherence to existing guidelines (also a problem in the acute setting).
- The need to make system changes to support better management of chronic disease generally. These changes included some form of patient enrolment and alterations to MBS items to expand the eligible providers and to increase flexibility of use.
- The ongoing gap in health outcomes for Indigenous Australians compared to non-Indigenous Australians.
Australian Health Insurance Association (AHIA)The AHIA is the peak body for health insurance agencies in Australia and represents the interests of its Health Insurer members. These members are impacted on by the hospitalisation and treatment costs of preventable CVD. The AHIA advises that its members invest in preventative strategies where they are permitted under current legislation. The Association has an interest in improving the effectiveness of CVD management on behalf of its members.
Although not having used the National Service Improvement Framework for Heart, Stroke and Vascular Disease, the AHIA had key priorities that link with the critical intervention points.
- A key interest to the AHIA is improving the use of clinical guidelines. The AHIA believes there would be improvements in outcomes for CVD if the application of current clinical guidelines was enforced. The AHIA suggests legislation so that medical indemnity cover will only apply where it is proved that existing guidelines were used or that variation from guidelines was evidence based and defensible. The AHIA would encourage the adoption of a pilot program to make an electronic decision support tool available to GPs, for example, through existing GP systems (such as Medical Director) a pop up is activated when certain drugs are prescribed that asks key questions based on current guidelines and suggests actions also based on current guidelines.
- The value of mass media campaigns where they are not part of a broader multifactorial campaign and advises the cost-benefit should be carefully considered.
- The development of small but potentially effective localised and locally controlled activities to improve CVD health for Indigenous Australians.
National Aboriginal Community Controlled Health Organisation (NACCHO)NACCHO is the peak body for Aboriginal and Torres Strait Islander Community Controlled Health Services in Australia. Aboriginal Community Controlled Health Services are managed by Aboriginal and Torres Strait Islander people are locally focussed and provide a range of primary health care services to Aboriginal and Torres Strait Islander Australians. The death rate from CVD is up to 3 times higher for Aboriginal and Torres Strait Islander Australians than for non-Indigenous Australians and equity to suitable early identification, intervention and ongoing care is a major concern.
NACCHO was involved in the development of the National Service Improvement Framework for Heart, Stroke and Vascular Disease and considers the critical intervention points and the underlying evidence to still be sound. Like most stakeholders consulted, NACCHO believes the National Service Improvement Framework for Heart, Stroke and Vascular Disease has not been more comprehensively adopted due to a lack of resources associated with its release.
NACCHO expressed concern regarding:
- What it sees as disconnect between the NSIF and policy/program development for Aboriginal and Torres Strait Islander health.
- Resource issues for Aboriginal and Torres Strait Islander health, including access to GPs, limited outreach capacity to isolated individuals and communities and access to preventative and treatment services for CVD.
Australian General Practice Network (AGPN)The Australian General Practice Network is the peak body for Divisions of General Practice in Australia. Divisions of General Practice provide a range of supports to General Practice and advocate on behalf of general practice at regional, state and national levels.
Divisions of General Practice are also funded to support services for high priority disease groups, including chronic disease. They may employ or contract allied health or nursing clinicians to run complementary programs with general practice or to provide a direct clinical service, to which GPs can refer patients. The AGPN has links with the NHF, NSF, the Pharmacy Guild and Diabetes Australia.
The AGPN has not been particularly aware of the National Service Improvement Framework for Heart, Stroke and Vascular Disease and has not been using it. Key concerns for the AGPN with regards to CVD include:
- The development of strategies and guidelines that directly impact on or depend on general practice but have not considered the practicalities of implementation within the general practice environment. This can lead to difficulties in implementation of clinical guidelines within general practice, including the absolute risk assessment guidelines.
- The importance of making clinical guidelines available and user friendly though electronic support tools embedded in existing programs.
- The value of the Primary Care Collaborative in assisting general practice to use data and evidence to challenge current practice.
- The importance of contextualising strategy for general practice within the GP’s framework for care, which revolves around individual patient needs, considers the patient as a whole person rather than a specific disease and is still largely focused on the ill patient rather than the well patient. General practice is now moving into primary prevention as a core role.
- The importance of running initiatives to GPs through the Divisions of General Practice, which are generally seen as a key resource and credible source by GPs.
Australian Diabetes SocietyThe Australian Diabetes Society provides leadership in diabetes through Diabetes Australia. This includes providing algorithms and guidelines for diabetes clinical care. The president of the Australian Diabetes Society is Associate Professor Stephen Twigg. Associate Professor Twigg provided input into the review from his professional perspective as an endocrinologist.
Assoc Professor Twigg notes the strong correlation between Diabetes and CVD, with most people with diabetes dying from CVD. In addition pre-diabetes appears to increase risk of CVD mortality. The added complications diabetes require a different approach to risk assessment, diagnosis and treatment of CVD for those with diabetes or pre-diabetes and Associate Professor Twigg notes this should be taken into account when considering options to improve CVD management.
Particular areas of concern discussed include:
- The value of evidence in informing management of diabetes and CVD.
- The development and use of assessment guidelines that take into account the specific risks associated with diabetes and CVD.
- Targeting of protective medicines to the right people
- The importance of preventative strategies and the need for public policy to support these, for example improving access to physical activity opportunities.