Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

4.3 Delivery of follow-up services

Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

Page last updated: 17 April 2012

4.3.1 Planning for follow-up services
4.3.2 The process of the referrals and follow-up services
4.3.3 What follow-up services were requested?
4.3.4 What follow-up services were received?
4.3.5 Were the referrals necessary and the follow-up services those required?
4.3.6 Conclusions

One of the aims of the CHCI was to refer children to other services if the check found the child had health issues needing more specialist treatment or dental attention.

This section looks at which follow-up services were requested as a result of the checks, the services children received and the barriers to completing follow-up services. It draws on monitoring data collected by the AIHW, DHF and health services, reports, and qualitative information from the evaluation case studies.

4.3.1 Planning for follow-up services

This discussion focuses on CHCI follow-up service negotiations and provision, managed by DoHA and DHF. The health services in three of the evaluation case study communities were managed by DHF and two were managed by ACCHOs. Table 18 provides an overview of DoHA and DHF negotiations of CHCI follow-up service delivery.

Several DHF senior managers expressed frustration at the length of time taken by DoHA to sign off on Agreements 1 and 2. They later experienced similar frustration when signing off on variations to agreements due to procurement delays, logistical issues and the need to revise implementation plans. Several DHF officials felt that signing off took longer than necessary (given the tight time frame) because the Darwinbased DoHA staff had to refer all decision making to more senior officials in Canberra. One senior manager commented that the CHCI, including follow-up activities, was ‘micro-managed from Canberra’.


Table 18: Timeline and overview of the negotiation process and agreements for providing CHCI follow-up services
TimelineAction
21 June 2007The NTER, including child health checks, was announced.
10 July 2007The first child health check team was deployed.
17 September 2007The Australian Government and the NT Government signed a memorandum of understanding which, among other things, committed the NT Government to ‘cooperation, coordination and extra services in relation to the follow-up of the Child Health Checks … under arrangements to be determined in discussion with the AG [Australian Government]’.
Late October 2007Negotiations between DoHA and DHF to provide follow-up services in Central Australia commenced. DHF agreed to:
  • remote community health centre-based treatment of childhood conditions that require primary care intervention in the communities in which DHF is the key provider
  • delivery of dental services, including increased visits to remote communities, dental services to town camp children, referred services and dental care under general anaesthetic, where required, in Alice Springs Hospital and potentially other NT hospitals, depending on demand
  • delivery of ear health/hearing treatment services, including primary care in remote communities where DHF is the key provider, and audiology assessment and ENT specialist care for all children whose child health check revealed a likely need in this area, other referred services as required and ENT surgery, where indicated by full assessment, in Alice Springs Hospital (and potentially other NT hospitals, depending on demand) • echocardiography for referred children
  • paediatric review for referred children
  • a range of other specialist, allied health and other services for referred children
  • in communities in which DHF is the key provider, best efforts at providing child health checks to children (with appropriate consent) who are yet to be checked.
  • In agreeing to provide follow-up services, DHF noted that a lack of physical infrastructure, including staff accommodation, health centre space and dental facilities presented key challenges. Officers from both DoHA and DHF committed to jointly working out practical solutions that would be funded by the Australian Government to meet these challenges (DHF, correspondence to DoHA, November 2007).
Early December 2007The Australian Government requested a proposal from DHF to cover providing hearing/ENT and dental service follow-up in Central Australia, purchase of seven mobile hearing booths, purchase of three mobile dental units and lease of four dental vans.
January 2008DoHA wrote to Central Australian ACCHOs providing further detail of the follow-up to the child health checks and to inform ACCHOs of the funding available to provide follow-up services (DoHA correspondence, January 2008).
Late January 2008DoHA wrote to DHF inviting DHF to participate in planning and providing follow-up services on a NT-wide basis. DHF agreed to this request. DHF noted in their correspondence that the Top End ‘is a larger and more complex area and the extent to which we can complete the checks by 30 June 2008 is dependent on how quickly we can commence the process’ (DoHA correspondence, January 2008).
Early March 2008DHF triggered ‘Phase 2’ (CHCI follow-up activities) one month before signing any agreements with DoHA and based on verbal assurances that funding would be forthcoming. DHF commenced recruiting staff and procurement processes so as many follow-up services as possible could be provided by 30 June 2008 (DHF, submission to the NTER Review, August 2008).
March 2008DoHA wrote to Top End ACCHOs providing further detail of the follow-up to the child health checks and to inform ACCHOs of the funding available to provide follow-up services. Top End ACCHOs were asked to submit proposals within two weeks (DoHA, NTER, NT Emergency Coordination Centre correspondence, March 2008).
Late March 2008DoHA and DHF signed two agreements on providing CHCI follow-up services:
  • Agreement 1—relating to providing oral health follow-up services to Central Australian town camps
  • Agreement 2—relating to providing health care services (including allied health services)
(Delays in signing the agreements were a result of protracted negotiations about liability between the agencies).
Early April 2008DHF submitted a proposal for providing follow-up dental services for the Top End and Barkly regions. Later in April DoHA advised DHF that funding for the service delivery model proposed for the Top End would not be provided until all resourcing provided for Central Australia was close to being expended at which time DHF might apply for additional funding. A variation was proposed by DoHA to the existing agreement covering oral health follow-up services to include communities in the Top End and Barkly regions ‘where oral health services can be provided by 30 June using the funding already provided’ (DoHA correspondence, April 2008).
Late May 2008Agreement 1 was varied to allow for resourcing for Central Australian ENT, hearing and surgery and dental follow-up services to be used for follow-up services in the Top End and Barkly regions.
6 June 2008Agreement 2 was varied to allow for Central Australian PHC funding to be used to provide follow-up services to Top End communities. Of the $15 million received in 2007–08, $9.9 million was carried over into 2008–09. DoHA approved DHF’s retention of the $9.9 million only for expenditure up until 30 September 2008. The time frame of March 2008 (when the agreement was signed) to the end of the financial year in June 2008 was insufficient to procure additional dental vans for outreach in Central Australia, hence the need to roll over this funding to the next financial year.
December 2008An agreement was signed to continue providing follow-up hearing and ENT services to children who had a child health check, or were eligible for a check.
June 2009Closing the Gap funding for DHF Child Oral Health Action Plan 1 July 2009–30 June 2012 commenced.
Mid-2010Agreement reached that ENT specialist follow-up would continue until 31 December 2010. Other hearing follow-up services (including audiology) are continuing until 30 June 2012 under the EHSDI funding.
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DHF managers reported that, on a number of occasions, DHF and DoHA appeared to agree to a plan that DoHA later changed. For example, at the time of the roll out of follow-up services, several of the ACCHOs had no facilities or relied on the use of DHF facilities to provide dental services. Other ACCHOs had facilities but
often had problems recruiting dental professionals. Initially DoHA agreed that DHF would provide all dental services but DHF later learnt that DoHA had funded some ACCHOs to provide these. The funding contracts stated that ACCHOs and DHF were to liaise with one another to ensure services were adequately coordinated.
Despite efforts to share rosters, confusion and lack of coordination led to DHF and ACCHO dental teams arriving in one community at the same time.

Funding and delivery time frames for follow-up services

While DoHA provided approximately $15 million to DHF to fund follow-up activities in the Central Australian region, DoHA and DHF officers verbally agreed during the negotiation period that the level of additional services required could not be provided between 1 April and 30 June 2008. DoHA accepted that DHF would seek to roll over a large proportion of the funding into 2008–09 to finalise Phase 2 follow-up service delivery over ‘a realistic time period’ (DoHA, correspondence, April 2008).

The funding required for follow-up services in Central Australia limited the amount of funding and time left to provide services to Top End communities. In some cases, the infrastructure necessary to provide the followup services in the Top End was not operational until December 2009. One senior manager commented that the planning for the delivery of follow-up services highlighted DoHA’s limited understanding of the existing NT PHC system and the many difficulties associated with providing services to the small and geographically isolated communities scattered throughout the NT. This may also be a result of the speed of the decision making about the NTER and the child health checks and the lack of federal engagement with NT agencies during that process. Another senior DHF manager reported that DoHA focused heavily on rolling out the child health checks but there was no discussion about what would happen next. There appeared to be a general recognition that follow-up services would be needed and that both the Australian and NT governments needed to undertake considerable developmental work and advocacy, as evidenced by the memorandum of understanding signed on 17 September 2007 (Table 18).

However, active negotiations between the governments on actually planning to manage the follow-up requests did not occur until October 2007, several months after the child health checks commenced. Ideally, this detailed planning would have occurred before the health checks commenced in July 2007. Correspondence between DoHA and DHF in early to mid-2008 indicates that planning for the follow-up services was largely reactive (DHF correspondence March–June 2008).

DoHA had anticipated that the child health checks and follow-up referrals would largely be completed by 30 June 2008, at which point funding for the checks and provision of follow-up services was meant to cease. However, funding continued to be extended by relatively short periods of three to six months at a time. One participant described this as a ‘drip feeding’ method of funding, leading to uncertainty among service providers, economic risk taking by providers and an inability to plan in advance. The broader political context of an election, change of government, and new minister and Budget decision making parameters no doubt
caused uncertainty and influenced how DoHA operated in late 2007 and the first half of 2008.

Tight time frames meant that initially some services, especially dental and ENT, were only driven by supply. Services were provided according to the availability of specialist staff recruited from interstate. New models were developed over time that allowed services to be planned in response to need (see Box 3 and Box 4 in Section 4.4.2), although demand has generally exceeded the supply of specialist teams.

Two participants believed DoHA had pre-planned and showed a preference for funding dental and ENT surgical services because these were ‘high profile and showcased well in the media (interview, government officials). The decision to fund these follow-up services and follow-up PHC, however, is supported by the demand as reflected in the high number of referrals made for PHC, dental, tympanometry and audiology and paediatric services (see Table 19 in Section 4.3.3).


4.3.2 The process of the referrals and follow-up services

DoHA originally estimated that most child health checks would be complete by April 2008 and that followup services would be delivered intensively from this date. DoHA planned a regional approach to follow-up services, starting in Alice Springs and then moving to Darwin, East Arnhem, Katherine and Barkly regions in that order. Follow-up services to be provided included:
  • augmentation of primary health care services in the NT
  • the delivery of specialist ENT care
  • the delivery of oral health care services
  • the delivery of other specialist and allied health services.
DoHA planned that follow-up PHC would be provided by existing local service providers and paediatric services through DHF and ACCHOs. PHC and audiology services would be provided in local health clinics and oral health and some ENT specialist services provided as outreach services. Surgical services would take place in regional hospitals. DoHA saw its role as focusing on ‘monitoring, recording and progressing the delivery of follow-up, including the provision of PHC services where these have not already been delivered by existing services, and residual child health checks where these were not provided in the first place’ (DoHA and NT Emergency Coordination Centre correspondence to health service providers, May 2008). As previously discussed, agreements were drawn up with DHF and ACCHOs for these agencies to be responsible for service planning and service provision.

There were several issues associated with the plan to deliver an increased volume of health services in a short time frame in remote environments. For example, infrastructure and equipment needed to be procured, transported to remote communities, commissioned, and the workforce needed to be recruited. The Australian Army withdrew logistical support for CHCI activities when the ADF’s official NTER support operation concluded at the end of June 2008. This also reduced the program’s capacity.

Referral processes

The initial CHCI follow-up referral process was:
  • a copy of the referral was sent or faxed to the DHF
  • a copy was placed in the child’s medical file.
Political imperatives meant that DoHA had little time to plan the CHCI—either the checks themselves or the follow-up services. The checks began in Central Australia in the second week of July 2007 with referrals being written, sent to DHF, and some services provided by DHF before any system was developed to capture what follow-up services were being provided.

In many instances it proved difficult to reconcile the referrals made with follow-up referred services delivered. For example, a child’s records might indicate that a referral had been made but DHF has no record of receiving this referral. A labour-intensive and complex system was devised to reconcile the number of referrals made and follow-up services delivered. This involved specially employed PHC follow-up personnel or local staff doing an initial chart review for each child that received a child health check and later an exit chart review (Figure 4).

Many of the health service staff in the communities we visited highlighted problems with the chart review process. One health service manager reported that the follow-up referral process was confusing and not well coordinated and that the different organisations involved had their own agendas. The process of capturing the child health check and follow-up services information is probably the reason why, in nearly all of the evaluation case study communities, the resident health service staff perceived the CHCI as only a ‘data collecting exercise’.

Figure 4: Flowchart of the PHC data collection process

Figure 4: Flowchart of the PHC data collection process

Source: Correspondence from OATSIH (May 2008), NT Emergency Coordination Centre to health service providers.


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The level of confusion about referrals and delays in processing them varied. As previously mentioned, some referrals in Central Australia were actioned through existing systems before the data could be captured. There was generally less confusion in Central Australia than in the Top End because a paediatric liaison unit was already operating in Alice Springs and the number of referrals was fewer. In the Top End, referrals from DHF-managed remote health services and three ACCHOs were faxed to a central number within DHF where they accumulated without further action until October 2007. The large number of child health check follow-up referrals generally overwhelmed existing DHF systems in the Top End.

The pressure to provide follow-up services and complete outstanding child health checks within the 2007–08 financial year proved extremely challenging for staff from DoHA, DHF, ACCHOs and all community health service providers. Some areas coped better than others and this was probably due to some systems not experiencing the same pressure of numbers as other areas, especially in the Top End.


4.3.3 What follow-up services were requested?

Table 19 shows the number of referrals made as a result of the child health checks. The most common referrals were for PHC (38.6 per cent), dental (35.1 per cent) tympanometry and audiology (14.0 per cent) and paediatrician (12.1 per cent). The proportion of children receiving at least one referral was 69.5 per cent.

AIHW noted that there are several limitations with the data on follow-up referral requests, children’s health conditions and the follow-up services provided. These limitations need to be considered when interpreting data on follow-up services. Most importantly, AIHW considers that the data understates the number of children who received follow-up services and the number of services provided (AIHW and DoHA 2008, AIHW and DoHA 2009).


Table 19: Type and number of referrals made for Aboriginal children who had a child health check (July 2007–30 June 2009)
Type of referralNumberPercentage of children
Primary health care(a)3,62238.6
Paediatrician1,13112.1
Dental3,29335.1
ENT specialist8969.6
Tympanometry and audiology1,31614.0
Optometrist or ophthalmologist1171.2
Mental health services430.5
Speech therapist360.4
Physiotherapist90.1
Cardiologist290.3
Dietician or nutritionist500.5
Surgeon340.4
Urologist/renal physician40.0
Occupational therapist50.1
Family and Community Services (FACS)530.6
Housing150.2
Other clinician(b)330.4
Social worker650.7
Tests ordered(c)5415.8
Subtotal children with at least one referral(d)6,51669.5
Total children who received CHCs9,373

(a) - I ncludes PHC clinic, general practitioner or district medical officer, registered nurse, Aboriginal health worker and well baby clinic. Each child with multiple types of PHC referral is counted as having only one PHC referral.
(b) - I ncludes responses such as gynaecologist, obstetrics, dermatologist, prosthetic department, podiatrist and paediatric liaison nurse.
(c) - Includes pathology, echocardiology and radiology.
(d) - Defined as having one or more referrals for any of the above-mentioned services.
Source: AIHW and DoHA (2009).


4.3.4 What follow-up services were received?

As previously discussed, the child health check chart review process was a response to DoHA’s need to identify if children received the follow-up services they were referred to. AIHW encountered a number of issues in trying to analyse the follow-up data.

It appears that a number of children received referrals but did not receive a follow-up service because those reviewing the children’s charts determined that children did not need these services (see Section 4.3.5 for more detail on this point). Records of referrals were missing from some children’s charts and it was not possible to determine whether they had received follow-up services (AIHW and DoHA 2009).

The number of children who were given a referral at their first child health check, and the status of that referral, is listed in Table 20.


Table 20: Follow-up status of children given referrals during the child health checks by type of referral (2 November 2009)
Type of referral(a)
Number of children given a referral at their first check(b)(c)
Seen
Outstanding(d)
No longer require follow-up(e)
Referral missing(f)
Number
%
Number
%
Number
%
Number
%
Primary health care
2,678
2,154
80.4
226
8.4
90
3.4
208
7.8
Cardiologist
19
12
63.2
<5
n/a
<5
n/a
<5
n/a
Paediatrician
864
501
58.0
195
22.6
137
15.9
31
3.6
ENT specialist
668
380
56.9
178
26.6
90
13.5
20
3.0
Dietician or nutritionist
24
10
41.7
7
29.2
7
29.2
0
0.0
Tests ordered
415
166
40.0
44
10.6
58
14.0
147
35.4
Surgeon
28
10
35.7
5
17.9
<5
n/a
12
42.9
FACS and housing
59
21
35.6
13
22.0
19
32.2
6
10.2
Mental health services
36
12
33.3
10
27.8
12
33.3
<5
n/a
Optometrist/ Ophthalmologist
76
24
31.6
28
36.8
21
27.6
<5
n/a
Speech therapist
25
6
24.0
11
44.0
7
28.0
<5
n/a
Social worker
48
5
10.4
7
14.6
8
16.7
28
58.3
Other clinicians
516
32
6.2
17
3.3
7
1.4
460
89.1

(a) Excludes follow-up status of children referred to audiometry and dental services.
(b) Includes only children who had a complete chart review after their first child health check.
(c) Column does not add up to total as one child can have more than one referral.
(d) Refers to children who had not been seen by the services that they were referred to and still needed such services.
(e) Refers to children who had not been seen by the services they were referred to but who no longer required such services.
(f) Refers to children who received referrals at the child health check but for whom no referrals were mentioned in their chart reviews.
Source: AIHW and DoHA (2009).

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The highest proportions of outstanding services were for speech therapy (44.0 per cent), optometrist/ophthalmologist (36.8 per cent) and dietician or nutritionist (29.2 per cent). We could not identify any clear reasons why these particular services were less likely to have been provided. The existing (pre-CHCI) pattern of delivery for these services was, however, patchy and infrequent and likely to be inadequate to cope with even a small number of additional referrals.

DHF’s Remote Services Division did distribute referrals to other DHF divisions and program areas. This included the Mental Health and Family and Community Services program areas (DHF, NT DHCS NTER Phase 2 Agreements Status Report to End of May 2008) and to other government departments such as Territory
Housing (in the Department of Housing, Local Government and Regional Services). It seems that there was no system in place that could capture whether follow-up services were received outside the more traditionally recognised primary health care or secondary health care services. This was a significant deficiency, particularly given the critical role of services such as family, community, housing and social support in addressing the broader needs of Aboriginal children.
At the time of writing many children had not received the services to which they had been referred through the CHCI (see Table 21). As at 2 November 2009, 19.6 per cent of children referred for PHC follow-up, 42.0 per cent referred to paediatric services, and 57.4 per cent referred to other specialist services had not been seen by these services. By 19 July 2010, 39.8 per cent of children referred to dental services, 34.2 per cent to an ENT specialist, and 45.4 per cent to tympanometry and audiometry services had not been seen by these services.

These outcomes are not unexpected given the large number of referrals, the existing (pre-CHCI) service patterns for the main referral areas, including the already high workloads of some specialists, the time constraints and the rush to establish systems, the need to procure infrastructure and recruit staff, and general logistical problems. Not all these referrals, however, will be outstanding. Some children will no longer require the service they were referred to and some children will not be able to be traced for follow-up.

The number of follow-up services actually provided is likely to be greater than indicated in Table 21 because in some cases children received services but no chart review was completed and some received additional eferrals as a result of their initial specialist consultation. This occurred especially between ENT and tympanometry and audiology services and paediatric and ENT and/or tympanometry and audiology services. It is also possible that some children with a dental referral received follow-up services from ACCHOs that received funding for dental services independent of the NTER (AIHW and DoHA 2009).


Table 21: Number of children with a child health check referral and number of referrals provided (July 2007–19 July 2010)
Community(a)
Children with a referral from check(b)
Children with a referral from check and chart review completed(c)
Children seen at least once by referred service (number of referrals provided)(d)
Children seen at least once (%)(d)
Children who have not been seen (%)(d)
Primary health care (at 30 June 2009, chart review data at 2 November 2009)
A
63
53
49
92.5
7.5
B
226
9
2
22.2
77.8
C
27
25
15
62.5
37.5
D
59
61
58
95.1
4.9
All NTER areas
3,622
2,678
2,154
80.4
19.6
Paediatrician (at 30 June 2009, chart review data at 2 November 2009)
A
14
9
3
33.3
66.7
B
84
3
0
0
100.0
C
12
12
8
66.7
33.3
D
19
19
18
94.7
5.3
All NTER areas
1,131
864
501
58.0
42.0
Dental (at 19 July 2010)
A
73
45
61.6
38.4
B
221
49
22.2
77.8
C
23
10
43.5
56.5
D
48
38
79.2
20.8
All NTER areas
3,223
1,939
60.2
39.8
Ear nose and throat specialist(c) ( at 19 July 2010)
A
63
35
55.6
44.4
B
66
22
33.3
66.7
C
30
24
80.0
20.0
D
29
28
96.6
3.4
All NTER areas
1,625
1,070
65.8
34.2
Tympanometry and audiometry (at 19 July 2010)
A
61
13
21.3
78.7
B
57
45
78.9
21.1
C
30
16
53.3
46.7
D
14
11
78.6
21.4
All NTER areas
1,291
705
54.6
45.4
Other specialists (at 30 June 2009, chart review data at 2 November 2009)
A
44
32
4
12.5
87.5
B
52
1
0
0
100.0
C
8
8
4
50.0
50.0
D
15
15
8
53.3
46.7
All NTER areas
947
723
308
42.6
57.4

(a) - The CHCI in community E used non-standard forms and the referral information was not available for analysis, so is not included in this table.
(b) The number of children with referral does not equal the number of referrals because one child can have multiple referrals. Dental, and tympanometry/audiometry referral is based on the number of referrals made at the first child health check. ENT referrals also include referrals received at chart review.
(c) For PHC, paediatric and other specialist referrals, only children who received a chart review can be identified if they have or have not been seen by these follow-up services.
(d) For PHC, paediatric and other specialist referrals, number and percentage is based only on those who had a chart review completed.
For dental, ENT and tympanometry/audiometry, the data comes from separate dental and audiology data collections. The dental data does not include follow-up services provided by ACCHOs independent of NTER funding.
Source: AIHW and DoHA (2009); Data supplied by AIHW (August 2010).

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We estimate that all of the children in four of the case study communities (A, C, D and E) are likely to have received the follow-up services requested as a result of the child health check. In the fifth community (B) only a small proportion of children who were referred for follow-up services and whose medical charts were reviewed appear to have been seen (Table 21), with the exception of tympanometry and audiometry services. For a number of reasons, including staff resigning and an overwhelming workload due to the large number of PHC referrals, few chart reviews were completed at community B.

In any screening program there is a moral and ethical duty to follow up on the conditions identified. The level of follow-up from the CHCI, as at July 2010,
ranged from 42.6–80.4 per cent depending on the type of referral (Table 21). The total number of referrals was 10,404, of which 6,677 (64.2 per cent) had
been followed up and 3,727 (35.8 per cent) had not been followed up.18******

The timing of PHC follow-up services was dependent on the health service provider. For DHF health services (including case study communities A, C and D), PHC follow-up services were completed between May and December 2008. These services were largely provided by specially formed Helping Hands ‘fly-in/fly-out’ PHC teams.

The DHF referral data management system—established to monitor and manage follow-up services—was closed in Central Australia in early 2009. Reports in March 2010 indicated that the Top End system would be closing in the near future. The later time for the Top End reflects the higher number of referrals there and that Central Australian communities were first in line to receive follow-up services.

DHF tracked referrals to ensure that children received follow-up services. Table 22 provides an example of how this was done. In case study communities C and D, an equal number of initial and exit chart reviews were completed but community A completed fewer exit chart reviews than initial reviews. The percentage of chart
reviews completed ranged from 72 to 96 per cent. The AIHW has identified a number of limitations with the chart review data (AIHW and DoHA 2009), suggesting that the process and purpose of completing the chart review forms was not clearly understood by all health workers.

The delivery of follow-up services in 2008 and 2009 appears to have been delayed for logistical and infrastructure reasons. For example, some communities only received hearing booths in the latter part of 2009. Some children have required ongoing treatment by specialist services and, as discussed earlier, their follow-up is still active. Some children may have missed receiving their follow-up service because they failed to present or refused the service.


Table 22: Number of chart reviews completed in DHF health centres/communities (September 2009)
CommunityTotal expected chart reviewsInitial chart reviewsExit chart reviewsComplete (%)(a)
A1091027972
C64595992
D19018418396

(a) A chart review is complete when both an initial and exit chart review is done.
Source: Data provided by DHF (September 2009).


ACCHOs used different models to provide PHC and specialist follow-up services. In case study community E, PHC follow-up services were provided at the same time as the child health check (MBS Item No. 708). Specialist and specialised service referrals were dealt with as part of the normal secondary health service referral process. The health service in this community has developed a central tracking system to follow up on referrals made. The staff of the health service were confident that the referrals showing as outstanding as at June 2009 were new referrals and not referrals outstanding from the child health checks completed in 2007–2008. A relatively small number of children living at community E are waiting to receive ENT and dental services.


Table 23: Children’s follow-up referrals outstanding in case study community E (June 2009)
PeriodTotal number of 708s claimed for period—current patientsNumber not requiring chart review auditChart review audit completedFollow-up outstanding after chart review auditType of follow-up outstanding
200713845932Dental services
January–June 20084922271Dental services
July–December 20089125668Dental services
January–June 20093013179ENT and dental services

Source: Data supplied by community health service (March 2010).

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The health service in community B is an ACCHO that provides services to a population of over 2,000 people. Following the delivery of the child health checks, the health service was left to manage the provision of a large number of the CHCI follow-up referred services and continue to provide day-to-day services at a time the service was also required to identify a new auspicing body and transfer its governance arrangements.

We could not quantify the actual number of children in community B who received child health check followup services as very few chart audits were completed and no records were maintained after August 2008. At September 2008 children who received child health checks at community B received few follow-up referred services other than dental (although still only a small proportion of those who had a referral) and, more recently, audiology services (Table 24). Except in the case of ENT referrals, health service records show more follow-up referrals were made than are reported in the AIHW data. Many of these referrals were found among stored child health check forms up to six months after the child health checks were completed. The follow-up referrals were apparently not processed correctly or forwarded to the DHF by the visiting teams. Health service staff reported that a large number of children from community B were already on specialist waiting lists and there is the possibility that these children were re-referred as a result of their child health check.


Table 24: AIHW and community B health service data showing the number of children who received follow-up referrals and subsequent follow-up services following their child health checks (September 2008 and July 2010)
Number of children with a referral from child health checkNumber of children with referral who had a chart reviewNumber of children seen at least once by the referred service(a)
AIHW at July 2010Health service at Sept 2008AIHW at July 2010Health service at Sept 2008AIHW at July 2010Health serviceat Sept 2008
Primary health care226n/a9-2-
Paediatrician841033-07
Dental2212718-4972
ENT specialist66462-221
Tympanometry and audiometry57851-4564
Other specialists5281(b)1-00

(a) - Most services provided by services that routinely visit (e.g. DHF School Dental Service) and not services introduced as part of the CHCI.
(b) - Includes 71 referrals for echocardiograms.
Source: Data supplied by AIHW (August 2010); Data supplied by community health service (February 2010).

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The extent of the services provided by DHF to the health service in community B up to September 2008 was possibly limited to the service model and funding agreement between DoHA and DHF, for example:
  • for hearing—‘three visits to each community, provision of under 4-year-olds’ testing close to the community (requires sound booth) and surgical intervention (where indicated)’
  • for dental—‘a visit to each prescribed community with treatment provided as required, assessing and treating as required 100 per cent of eligible children’ (DHF correspondence, September 2008).
The health service in community B had neither a hearing booth nor a suitable dental facility and equipment until late 200919, preventing a large number of children from receiving follow-up services under this agreement. One visit by a dental team was never going to be sufficient to meet the community’s high needs given the high number of dental referrals (271 children).

Subsequent agreements between DHF and DoHA (from September 2008) stipulated that DHF would only be responsible for providing outstanding child health check follow-up services to health services for which DHF is responsible. The health service in community B has since been provided with funding by DoHA to buy additional dental services for children and adults. Their efforts in sourcing these additional services have met with limited success to date.

It appears that the CHCI resulted in increased availability of specialist services, in particular ENT, hearing and oral health services. It is not possible, however, to accurately identify what follow-up services children received. There are a number of issues concerning the completeness of the CHCI data collected by the AIHW:
  • the belated introduction of systems to capture data
  • community-based staff failing to process referrals (to AIHW and/or DHF)
  • initial confusion about managing referrals
  • the large number of referrals generated by the child health checks
  • the lack of capacity in existing systems to process these referrals
  • guardians not providing consent to pass on information to AIHW
  • the burdensome data collection system (repeated chart audits) that caused errors in data collection or the failure to collect data.
We concur with AIHW’s view that it is likely that more follow-up services were received than the data indicates.


4.3.5 Were the referrals necessary and the follow-up services those required?

We relied on the advice of participants, many of whom are specialists in their fields, and on published documents to try to determine if the follow-up referrals supplied and follow-up services delivered were necessary and matched the need. We also examined referral data from the larger communities to see if there were trends or patterns in the types of referral made or differences in referral practices between teams providing child health checks. Based on the referral data alone, it was difficult to come to clear conclusions as to whether individual referrals were necessary or not.

A relatively high proportion of referrals were not deemed necessary by some specialists receiving the referrals. There was consensus among the paediatricians interviewed, and in publicly available documents, that the doctors who did the child health checks over-referred children for specialist paediatric review. The conditions most frequently over-referred were suspected heart murmurs, being underweight, ear infections, scabies and untreated caries.

The large number of referrals and echocardiograms for suspected heart murmurs was considered by some paediatricians to reflect the inexperience and the lack of confidence of doctors working outside their normal scope of practice, particularly cardiac conditions. For example, in Central Australia a paediatrician assessed
68 referrals for echocardiography and identified that 35 children (51 per cent) had already been investigated, 17 children (25 per cent) were to be followed-up in their remote community with an outreach service, and the remaining 16 children (24 per cent) were scheduled to receive echocardiograms. Similarly, a number of children were referred to paediatricians for being underweight/stunting. Specialists considered that these referrals were not always necessary. The paediatricians considered that few children not already on their lists, and few medical conditions of any significance, were brought to their attention as a result of the child health checks.

Doctors already in the NT health system raised issues about different trends in the types of referrals made by CHCI taskforce teams working at different times in the same community (Submission number 70, NTER Review). After reviewing children’s notes, one doctor stated that trends in referral were readily identifiable by practitioner. This doctor observed that, ‘it was obvious that when one team was in a community they highlighted one issue, and when replaced by another team they highlighted a totally different issue’ (interview, health professional).

We examined CHCI data held by AIHW to investigate this issue and found that where more than one taskforce team did the child health checks in the same community, there were differences between teams in the type and number of referrals made. Variations were also noted within and across communities. It is unlikely the health characteristics of children presenting in the same community would be so different as to explain this phenomenon.

Trends or patterns of this type might be due to any number of factors. It would be speculative for us to settle on only one or two factors, especially as it relates to ear disease and hearing problems where the referral pathway is complex. One community health service manager described the ear/hearing referral pathway as a ‘nightmare’ and the referral system would be even more complex for a doctor new to the NT health system. For example, Table 25 shows the referral pathways for a child with chronic suppurative otitis media (CSOM) not better after 16 weeks treatment. Four referrals are required.Top of page


Table 25: Referral to specialist
Refer to:ENT specialistPaediatricianSpeech pathologistHearing test (audiologist)
    High priority
Perforations
    Unsafe perforation in very top of eardrum
    Possible cholesteatoma
Yes
    CSOM not better after 16 weeks treatment
Yes
Yes
Yes
Yes
    Perforation of both eardrums, size more than 30 per cent
Yes
    Any perforation present for more than 3 months, age 0–7 years
Yes
Speech development
    Ear disease and language delay
Yes
Yes
Yes
Yes
    Family or school concern about hearing, speech, language development, behaviour
Yes
Yes
Yes
    Moderate or greater hearing disability—or clearance to fit hearing aid
Yes or Yes
    Red fleshy mass (polyp) in middle ear canal
Yes
    OME in both ears, or for more than 3 months
Yes
Yes

Source: CARPA (2009).


In the context of the child health checks, and depending on a child’s condition, the practitioner might decide to refer to a paediatrician for the specialist to decide if the other referrals are required, or refer to the ENT specialist and let this specialist decide if hearing tests or speech therapy are required. Or the practitioner may refer directly for tympanometry and audiometry, or make all four referrals at the same time.

Dental services that received follow-up referrals from child health checks felt that most were appropriate, as the staff working for dental services already knew that ‘all the children needed oral health checks’. For this reason, children who received a CHCI follow-up referral for dental services were not given greater priority over other children already on lists, unless the referral was marked as urgent. This approach appears to have been appropriate as the children who did not have a child health check experienced untreated caries approximately 10 per cent more than those children who received a check (Table 26).


Table 26: Problems treated by whether or not a child health check was undertaken, children who had a dental check as part of the CHCI (July 2007–30 June 2009)
Problems treatedChild health checkNo child health check
NumberPer centNumberPer cent
Untreated caries79747.735757.3
Gum disease90554.134755.7
Broken or chipped teeth due to trauma402.3254.0
Abnormal teeth growth251.4101.6
Missing teeth291.781.2
Mouth infection or mouth sores50.281.2
Dental hygiene (including plaque and calcification)925.5416.5
Other38322.918730.0
Total number of children1,670n/a622n/a

Notes: This is a multiple response item. If a child was treated for a dental problem at any one of their dental checks, they were counted once against that particular problem. Data about problems treated were missing for 3.4 per cent of children. This is a subset of the total number of dental referrals from a child health check (which was 3,223 referrals to 19 July 2010).
Source: AIHW and DoHA (2009).

Top of pageA similar approach was taken to providing audiology and ENT services. Service provision was not limited to children who had received a check. NT hearing and ENT service providers were already aware of the high level of unmet need for hearing and ENT services among children living in remote communities; however, audiology and ENT referrals reflected more complex pathology than the dental referrals. Hearing and ENT referrals were not always viewed as reliable. Referred children were commonly reassessed due to the inexperience of the doctors doing the checks as there is a high degree of difficulty in doing these examinations. The CHCI ear examination required only visual otoscopy and children were not examined for otitis media with effusion and the protocol for referral stated to refer only for bilateral disease.

While the reason for referral, and to whom the referral was directed, may not have been deemed reliable at times, it is generally acknowledged that all children referred were likely to need ear/hearing assessments and possible review by an ENT specialist. Over 60 per cent of the children referred for audiology services at their child health check were found to have a hearing loss, while over half of the children who had a non-audiology referral or who did not have a child health check had a hearing loss (Table 27).


Table 27: Prevalence of hearing loss by referral status (July 2010)
Referral statu
Hearing loss
Yes
No / missing
Total
Number
Per

cent

Number
Per cent
Number
Per

cent

CHC audiology referral44262.726337.3705100.0
CHC non-audiology referral (a)1,18051.61,10948.52,289100.0
Non-child health check50150.050250.11,003100.0
Total2,12353.11,87446.93,997100.0

(a) Children who had a child health check but did not have an audiology referral.
Source: Data supplied by AIHW (July 2010).

The more recent approach taken by DHF in providing follow-up audiology/ENT services appears to have been effective in introducing a case management service delivery model for children needing ongoing care from multiple service providers. This relieves community PHC providers of an onerous coordination role. It has also increased children’s access to audiology and ENT services.

While it was too early to determine the impact of the case management approach on ear disease outcomes, it would seem an appropriate response given the complexity of the clinical pathway required over extended time frames to address recurrent and chronic ear disease. DHF has recently reported that during 2009–10, 96.4 per cent of ENT surgical services delivered throughthe ‘Closing the Gap’ program were performed, and the low rate of surgery cancellations is partly attributable to the CHCI model of hearing and ENT service provision (DHF 2010a). Further information on the case management service delivery model for ENT and hearing services is included in Box 3 in Section 4.4.2.Top of page

The impact of child health check referrals on existing services

The resourcing related to child health check referrals was perceived as an opportunity cost by some DHF and ACCHO service providers. Staff at a number of service providers mentioned that the large amount of money spent on ENT surgical services could have been put to better use to develop a comprehensive and coordinated preventative, treatment and rehabilitative hearing health service. It would seem that this is partly about opportunity costs, but also partly about the lack of clinical consensus among health professionals on the best way to treat ear disease in Aboriginal children. A criticism was that following ear surgery children were not offered hearing rehabilitation services. The surgery on its own was inappropriately considered a ‘cure’.

As discussed previously, the need to recruit a workforce from interstate meant that the services provided to communities were largely supply driven. Health staff in several of the case study communities complained that visits from specialist services were made at short notice. Others stated that the need to provide pre- and post-operative care for ENT surgery prevented them from carrying out their normal duties. Coordinating the transport of children to regional centres for reviews and surgery was a stress on health service staff in some communities. On the other hand, guardians reported that they were very satisfied with their experiences in attending regional centres for dental and ENT surgery.


4.3.6 Conclusions

Tight time lines and a preoccupation with implementing the child health checks meant that planning for the CHCI follow-up referrals commenced late and was done under significant pressure. As a result there were a number of problems with the planning process, including protracted negotiation processes. The political context at the time and barriers associated with the lack of infrastructure and capacity to deliver follow-up services also influenced the planning process and contributed to short-term funding agreements and delays in implementing funding agreements.

A large number of follow-up referrals were generated as a result of the child health checks, with 69.5 per cent of children who had a check receiving at least one referral. Given the acute lack of infrastructure and resources needed to provide these follow-up services to remote communities, this level of referral was too much for existing NT health services to deal with and the referrals exposed a ‘bottleneck’ in the NT health system.

Many children have not received the services to which they have been referred. The level of follow-up ranged from 42.6–80.4 per cent, depending on the type of referral, with 64.2 per cent of the total referrals followed up. This leaves 35.8 per cent, or a total of 3,727 referrals, that have not been followed up. Some follow-up services were better able to cope with the volume of referrals than others and the bottleneck was not as severe. Despite increased access to services, the demand for many follow-up services still exceeds the capacity of the system and a bottleneck in the referral pathway remains. This is especially the case for ear health where many children received multiple referrals throughout the CHCI and as at 31 December 2010, 2,000 outstanding ENT referrals remained.

The cumbersome systems for processing referrals and collecting data are likely to have resulted in underreporting of the number of follow-up services received. Importantly, the provision of dental and hearing (including audiology) follow-up services is ongoing until 30 June 2012.

It is not possible to report conclusively on the quality of the child health check assessments and how many unnecessary follow-up referrals may have been made. The differences in referral patterns between taskforce teams working in the same community indicate inconsistencies in referring between different doctors. This is likely to reflect inexperience and the lack of confidence of some doctors working outside their normal scope of practice and some over-referral.

Many children who received, or were eligible to receive a child health check, were provided with increased access to dental, tympanometry, audiology and ENT services once the necessary infrastructure was in place and recruitment of specialists and specialised staff finalised.

Most participants believe that without the follow-up referred services provided, some children (both those who did and did not get child health checks) may have never received the specialist services they needed. Many, though, were uncomfortable with the ‘surge’ or ‘blitz’ approach to delivering these services as necessitated by the CHCI and its time frame. While generally unhappy with most aspects of the CHCI, both DHF and ACCHO health service providers expressed satisfaction that Aboriginal children’s previously unmet health needs, and of which they already knew and had been advocating for increased services for some time, were recognised and met as a consequence of the CHCI.

19 - A hearing booth was delivered to community B and commissioned around December 2009 and there has been catch-up in children receiving audiology services since then.



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