Effective/Appropriate/Efficient3.01 Antenatal care
3.02 Immunisation (child and adult)
3.03 Early detection and early treatment
3.04 Chronic disease management
3.05 Differential access to key hospital procedures
3.06 Ambulatory care sensitive hospital admissions
3.07 Health promotion
Responsive3.08 Discharge against medical advice
3.09 Access to mental health services
3.10 Aboriginal and Torres Strait Islander people in the health workforce
3.11 Competent governance
Accessible3.12 Access to services by types of service compared to need
3.13 Access to prescription medicines
3.14 Access to after-hours primary care
Continuous3.15 Regular GP or health service
3.16 Care planning for clients with chronic diseases
3.18 Aboriginal and Torres Strait Islander people training for health-related disciplines
Sustainable3.19 Expenditure on Aboriginal and Torres Strait Islander health compared to need
3.20 Recruitment and retention of clinical and management staff (including GPs)
Tier 3, Health System Performance, includes measures that address effectiveness, appropriateness, efficiency, responsiveness, accessibility, continuity, capability and sustainability of the health system. The HPF also recognises that safety is a measure of health system performance, but this is reported by alternative frameworks (ACSQHC 2009). Effectiveness, appropriateness and efficiency are measures which show progress towards achieving outcomes within established standards and meeting cultural requirements. These measures link efficiency with effectiveness to show how gaps are being addressed through continuity, coordination and adequate resources. Measures of responsiveness show the degree of client orientation within the system, and are analysed in terms of how the health system attends to values held by Aboriginal and Torres Strait Islander peoples, as articulated in the Cultural Respect Framework (SCATSIH 2004). Accessibility shows measures of whether people have been able to access health care as needed. Continuity looks at choices in accessing care and pathways and barriers along the patient journey. The skills and knowledge of the people who work in the health system are described, as well as the infrastructure which enables the system to deliver. The measures in Tier 3 incorporate population health, primary health care and secondary/tertiary care services. The measures deal with a range of programs and service types including child and maternal health, health promotion, early detection and chronic disease management, continuous care, access to care, the health workforce and adequacy of resources.
All of the Tiers in the HPF are inter-related and readers are encouraged to consider how measures interact. For example, measure 3.01 Antenatal care is enhanced by considering it as a protective factor as well as an outcome. Antenatal care provides mothers with information and support which can reduce health risk behaviours such as tobacco use during pregnancy (measure 2.19) which in turn, is related to low birthweight (measure 1.01).
Similarly, measure 3.19 Expenditure on Aboriginal and Torres Strait Islander health compared to need is enhanced through awareness of issues outlined in measure 3.12 Access to services by types of service compared to need, and all of the measures outlined in Tier 1 which demonstrate the equity issues which underpin measures of effectiveness. Health workforce development hinges upon measures in Tier 2 such as educational attainment (measures 2.04, 2.05 and 2.06).
Future directions for Tier 3 include further research and analysis to effectively measure the cultural competency of the health system. This issue connects the ability of the system to deliver appropriate care, a patient’s perspective of the health system and whether patient experiences have involved barriers to effectiveness. Stakeholder feedback on the development of the 2010 report demonstrated keen interest in the issues of the capability of the health workforce (both clinical and non-clinical) to deliver culturally safe care. Research and analysis is being undertaken to better understand differential access to key hospital procedures and discharge against medical advice.