2015-2018 4-yearly report: Ten trends in 10 years

Ten trends in 10 years: South Australia’s health system performance over the last decade

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Fifteen years ago, the then South Australian Minister for Health launched the Generational Health Review, chaired by John Menadue AO. Its subsequent report called for system reform to tackle increasing budget and demand pressures that were considered unsustainable for hospitals and the workforce, and sought a change in focus towards implementing health promotion, illness prevention and early intervention measures.

The Health Care Act 2008 emerged from this review, as did the Health Performance Council — the latter created to report to the Minister for Health on population health outcomes, health system performance and quality of care.

In the 10 years since, both the quality of care and patient outcomes have generally improved. By world standards, South Australia’s health system delivers effective services to the community and responds well to health-care needs that range in complexity across lifespans and affect families, friends and colleagues in different ways. However, there remain many opportunities for improvement in the next 10 years, particularly in quality and safety areas, in productivity areas, in the workforce, and for specific population groups within which health outcomes lag to an inexcusable degree behind those of the population average. The decade ahead is one of opportunity for South Australian health services, with the current Minister for Health and Wellbeing establishing new structural arrangements and reform plans that include focuses on clinical governance and patient safety, and on clinician and consumer leadership.

After a decade of analysing data, reports and other aspects of South Australia’s health system, the Council has decided to include in this report this ‘10 × 10’ overview of its findings, based on its analysis of 10 important indicators over 10 years.

Quality of care has improved

The South Australian media’s reports of crises and mismanagement in SA Health tell only part of the story of health services in the state. Despite increasing demands on the public health system, including more patients being treated in emergency departments and admitted to hospital beds, the quality of care is improving in areas ranging from cancer and stroke care to maternity care and orthopaedic surgery.

Five-year survivals for all cancers increased from 60 per cent for 2000–2004 diagnoses to 66 per cent for 2010–14, as Table 1 shows. The corresponding increases, by primary site of cancer, were from 87 per cent to 95 per cent for prostate cancer, 86 per cent to 90 per cent for female breast cancer, 61 per cent to 68 per cent for colorectal cancer, and 11 per cent to 15 per cent for lung cancer. A decrease in five-year survival for primary site of skin cancer (melanoma) from 93 per cent to 89 per cent ran counter to the general trend.

Five-year survival figures for all cancers in South Australia during the period 2010–2014 (66 per cent) were very similar to national averages reported by the Australian Institute for Health and Welfare (68 per cent for the period 2009–2013). However, Table 1 highlights differences between specific population groups; of note are five-year survival rates by Aboriginal status and according to socio-economic status (SES) of geographic area of residence.

Table 1: Five-year period survival rates, South Australia by specific population groups and cancer type (by percentage)
 

All cancers

Prostate cancer

Female breast cancer

Colorectal cancer

Lung cancer

Skin cancer (melanoma)

Diagnostic period

2010–⁠2014

66

95

90

68

15

89

2005–⁠2009

64

91

89

65

12

90

2000–⁠2004

60

87

86

61

11

93

Sex

Male

66

95

67

13

85

Female

67

90

68

17

93

Aboriginal status

Non-⁠Aboriginal

66

95

90

68

14

89

Aboriginal

39

79

73

58

21

SES status of area

1 (lowest)

60

92

88

63

14

86

2

64

93

89

67

14

89

3

66

95

89

69

13

88

4

70

97

92

68

16

91

5 (highest)

72

99

92

72

17

89

Remoteness of area

Major city

66

96

90

68

14

88

Inner regional

68

94

89

69

18

90

Outer regional

65

94

90

65

17

88

More remote

66

94

93

65

12

92

Source: South Australian Academic Health Science and Translation Centre (Health Translation SA) 2018, ‘Table 4: Five-year period survival (95 per cent CL), SA, 2010-2014’, Health System & Service Reform in South Australia, Phase 1 – Insights from an Evaluative Case Study of Transforming Health

In October 2014, SA Health published Stroke Management: Procedures & Protocols, which was developed by the Statewide Stroke Clinical Network and based on national best-practice guidelines known to provide good patient outcomes, including within designated stroke units in key hospitals across South Australia. The implementation was part of Stroke Clinical Improvement Project of ‘Transforming Health’. Audits over the past 10 years show 67 per cent of South Australians diagnosed with stroke received 90 per cent of acute hospital care in the state’s stroke units, on par with average across-Australia performance (2017 national adherence to the ‘Acute Stroke Clinical Care Standard Indicators’).

Death from stroke in South Australia, as a proportion of the population, is decreasing, roughly halving from 39.6 deaths per 100,000 population (standardised) in 2007 to 22.4 in 2017. However, the overall Australian rate has reduced in a similar fashion, as Figure 1 shows.

Figure 1: Number of deaths from stroke per 100,000 population, South Australia and Australia by calendar year

Source: Australian Bureau of Statistics, cat. no. 3303.0

Age-standardised rate

Deaths from stroke defined as cause of death ICD-10 codes I61–I64 & G45

However, the Council’s reporting has revealed there is still too much variation in the quality of care: the difference between access to care for the general population and specific population groups, such as Aboriginal South Australians or people living in rural and regional regions of the state, remains great. High-quality care for all is not a reality. The principles that underpinned SA Health’s ‘Transforming Health’ — that care should be ‘Patient-centred’, ‘Safe’, ‘Effective’, ‘Accessible’, ‘Efficient’ and ‘Equitable’ — are not always evident in the standards of care.

There are also services about which the Council does not know enough. Despite commitments from the previous government’s ministers in response to the Council’s 2014 four-yearly report, What’s Working, What’s Not (Appendix Six), the Council has not received or been able to access the private-hospital data that would enable it to build a system-wide picture of the South Australian health system and its care outcomes. For example, the Council cannot examine the number of unplanned hospital readmissions between private and public hospitals. Unplanned readmissions are a measure of issues that may exist with the quality, continuity and integration of care provided to patients during or after their original hospital admission, whether in a private or public facility. Without private-sector data, the Council cannot examine the extent of these issues and their costs to the health system.

Focusing on patient safety will pay off

In the wake of publicly-reported breaches in patient safety such as the sub-standard care of the Oakden Older Persons Mental Health Service and chemotherapy under-dosing caused by clinical governance failures, the South Australian Government has prioritised safety and clinical governance. It has committed to establishing a clinician- and consumer-led Commission on Excellence and Innovation in Health, and to increasing the use of data analysis for quality improvement, both of which are intended to improve service quality and safety.

Analysis by the Grattan Institute indicates that South Australia has the best incident reporting system among the states. Introduced in 2010, SA Health’s Safety Learning System (SLS) Incident Management module supports SA Health staff to record, manage, investigate and analyse patient and worker incidents in their workplaces. The SLS also records details of feedback received from members of the public, either as consumers or on behalf of family and friends who have received health care. The SLS categorises feedback as a complaint, compliment, suggestion or advice. Year-on-year, more SA Health consumers and their carers, families and friends are providing this feedback and, over time, proportionally less of this SA-Health-recorded feedback is categorised as complaints.

Figure 2: Number of instances of consumer feedback recorded as received by SA Health by financial year

Source: SA Health, customised SLS extract

All feedback includes compliments, complaints, suggestions and advice

Excludes feedback ‘rejected’ by SA Health (SLS classification)

Data prior to 2010–11 not available

There was a statistically significant increase in the rate of hospital-acquired complications in South Australian public hospitals between 2009–10 and 2015–16. The number of hospital-acquired infections remained steady.

Figure 3: Number of hospitalisations (inpatient separations) with an adverse event per 100 hospitalisations, public hospitals, by financial year

Source: Productivity Commission, Report on Government Services, public hospitals attachment tables

Age-standardised rate

Data prior to 2009–10 and after 2015–16 not published

Figure 4: Number of hospitalisations (inpatient separations) with an infection following a procedure per 100 hospitalisations, public hospitals, by financial year

Source: Productivity Commission, Report on Government Services, public hospitals attachment tables

Age-standardised rate

Data prior to 2009-10 and after 2015-16 not published

Accessing some services is more difficult

Access to services remains a major problem for some South Australians, and is more difficult for members of some population groups than others.

Ambulance ‘Code 1’ median response times — relating to immediate responses requiring lights and sirens — remained at about 10 minutes from 2007–08 to 2016–17, and are similar to the weighted average for all states and territories in the period.

Figure 5: Ambulance emergency response times, South Australia and Australia

Source: Productivity Commission 2018, 'Table 11A.3 Ambulance code 1 response times (minutes)', Report on Government Services 2018, Ambulance services attachment tables

Response times commence from the following time points: NSW, Queensland and WA from transfer to dispatch. Victoria, SA, Tasmania, NT and the ACT from first key stroke. Statewide 50th percentile

‘States and territories weighted average’ calculated by HPC Secretariat

The proportion of patients seen on time at public hospital emergency departments in South Australia peaked at 76 per cent in 2011–12 (81 per cent for Aboriginal people) and declined to 60 per cent in 2017–18 (69 per cent for Aboriginal people).

Waiting times for public dental services have increased dramatically. The median waiting time for an offer of public general dental care for people living in South Australia increased from 105 days in 2013–14 to 405 days in 2016–17. The median waiting time for an offer of public general dental care was similar for non-Aboriginal people (405 days) and Aboriginal people (406 days). However, median waiting times were inversely correlated with socio-economic status (SES) of area: 420 days for people living in the bottom SES quintile compared to 395 days for people living in the top SES quintile (Appendix Five: SA Health annual report on progress against advice in the Council’s four-yearly report 2014).

Waiting times for elective surgery in South Australian public hospitals increased over the same period. The median waiting time for elective surgery across all South Australian public hospitals was 34 days in 2011–12 and reached 42 days in 2017–18.

Figure 6: Waiting times for elective surgery in public hospitals by financial year

Source: Productivity Commission, Report on Government Services, public hospitals attachment tables and SA Health customised BLIS extract (2017–18)

Consumer confidence is steady, but better consumer communication is needed

Consumer confidence in the South Australian public health system has held up well over the past decade, as demonstrated by responses to surveys intended to gauge consumer confidence in doctors and nurses. But responses remain at below expected levels for consumer involvement in discharge information, perhaps a significant measure of how well the health system is succeeding in caring for consumers transferring between hospital and community or primary care. There is evidence that there is not enough being done to actively seek, encourage and evaluate feedback from consumers and other users of the system.

Patient-centred care is defined by the Picker Institute as health care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers, and Picker definitions are applied by SA Health. Picker includes four elements in its core domain of care regarding discharge information provided to consumers as part of their health care. These are shown in Figure 7. All four elements have remained relatively steady for South Australian public hospitals from 2012 to 2017.

Figure 7: Consumer involvement in discharge information, South Australian public hospitals, by calendar year

   Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

   Before you left hospital, were you given any written information or printed information about what you should or should not do after leaving hospital?

   Did a member of staff tell you about any danger signals you should watch for after you went home?

   Did the doctor or nurses give your family or someone close to you all the information they needed to help care for you?

Source: SA Health, customised SACESS extract

Excludes respondents who answered ‘don’t know’ or refused to answer

SACESS measures experiences of care reported by South Australians who spent at least one night in a public hospital within South Australia, and who were aged 16 years and over; not of Aboriginal or Torres Strait Islander descent; not admitted for maternity, psychiatric, substance abuse, chemotherapy or renal dialysis episodes of care; and proficient in spoken English.

SACESS does not include the Women’s and Children’s Hospital

Data prior to 2012 not available

SA Health promises a system that is consumer-centred, and for good reason: understanding consumers’ experience of care is central to understanding how well the health system is working and the extent to which it is delivering a person-centred service. But there is not enough activity in gathering, recording and listening to the voices that would provide evidence of that experience. While SA Health publishes an annual report, Measuring Consumer Experience, which collates the output of the South Australian Consumer Experience Surveillance System (SACESS) telephone survey of selected public hospital inpatients, the survey itself excludes many groups of consumers with important experiences to share, including potentially vulnerable population groups such as Aboriginal health consumers and people who do not speak English well enough to complete a telephone survey.

Costs are increasing

In 2003, the Generational Health Review concluded that on a per capita basis, South Australia spends more money, and has higher utilisation rates, more health professionals and more beds than other states and territories.

Little has changed in the 15 years since. South Australia’s average cost per admitted acute weighted separation (hospitalisation) is above the national average, which can reflect a less efficient service even when adjusted for casemix. Casemix adjustment takes account of variation in the relative complexity of the patient’s clinical condition and of the hospital services provided, but cannot capture all other influences on length of stay. South Australia has growing demand for public health services and an ageing population.

Figure 8: Average cost per admitted acute weighted separation, excluding depreciation

Source: Productivity Commission, Report on Government Services, public hospitals attachment tables

Data prior to 2012–13 not published

The cost of admitted hospitalisations is placing increasing pressure on the SA State Budget and on health’s share. As a result, the public health service is currently being asked to examine the factors that influence costs and how they may be managed differently while maintaining quality and effectiveness. Reforming how the service works is on the SA Health strategic agenda, with prevention, integration between health services, and strengthening home-care alternatives among the options.

The workforce needs more attention

Most of South Australia’s health budget is spent on the staff critical to providing quality care and services — the people who are facing more complicated and complex demands from more patients. Yet it seems that policy makers may at times pay too little attention to the needs, ideas or experiences of SA Health staff.

Large-scale change programs such as ‘Transforming Health’ (2015–2017) raised expectations among health staff about how and where they would work. However, Health Translation SA’s ‘Evaluative Case Study of Transforming Health’ (2018) found some staff felt unsupported and unclear about governance and authority after the changes. As the Council noted in the sixth edition of Monitoring Implementation of Transforming Health, SA Health staff were asked to assess the statements ‘this organisation is good at learning from its mistakes and successes’ and ‘my work area encourages me to be innovative’. Of those who responded, 46 per cent agreed or strongly agreed.

The Council also noted in that report that ‘Transforming Health’ implementation could have been adversely affected by the acceleration in executive turnover. Below-executive-grade staff turnover remained steady.

Figure 9: SA Health staff turnover rate by financial year

Source: SA Health, customised CHRIS extract

In calculating staff turnover rate, the Health Performance Council applies the SA Health Workforce definition: number of SA Health staff who separated from SA Government entirely as a percentage of average monthly headcount

Executive-level employees: SAES levels 1 & 2 and EXEC levels A–F

Action to increase diversity in the workforce has stalled. In 2002, the South Australian Strategic Plan aimed to increase the participation of Aboriginal people in the South Australian public sector, spread across all classifications, to 2 per cent, aligned to population make-up. The current proportion in SA Health is 1 per cent. This may be a missed opportunity with direct implications both for Aboriginal employment and on the consumers and staff who would benefit from receiving and working with culturally sensitive personnel.

Figure 10: SA Health Aboriginal workforce participation by financial year

Source: SA Health, customised CHRIS extract

South Australia’s Strategic Plan target calls for 2.0% of the public sector workforce to be Aboriginal persons.

Working differently will make a difference

The pressures on the health services of the past decade show no signs of diminishing. Costs are increasing in a sector being asked to perform more services for an increasingly ageing population. Every year, the health workforce is asked to do more with less. But there are ways to manage the pressures, if and when the system chooses to explore and implement those best suited to this state and its circumstances. Internationally, a proactive attitude towards capitalising on new and emerging research and technologies, a commitment to evidence-based decision-making, and maximising the value of the workforce have been shown to have real and measurable impacts on improving quality, safety and outcomes. The Council suggests that listening to people — consumers, carers, family members, communities and health staff in all population groups in towns and centres and hospitals across the state — will be a great place to start.