HEALTH MATTERS. Collaboration in healthcare. Victorian Healthcare Association. citizens juries co-production team-based care federal reform

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1 HEALTH MATTERS Victorian Healthcare Association Issue 2 [ SEPTEMBER 2011 ] Collaboration in healthcare citizens juries co-production team-based care federal reform

2 This issue 5 Citizens juries: a growing trend in healthcare Chairman s Message Directors must explore collaboration 3 CHAIRMAN S MESSAGE Directors must explore collaboration 4 CHIEF EXECUTIVE S MESSAGE Recognising the intrinsic value of collaboration 5 Citizens juries: a growing trend in healthcare 6 East Grampians plan to integrate nursing and paramedic skills 7 Community paramedic program for rural and remote areas 8 Ambulance and health service collaboration improves rural access 9 New research alliance set to explore community-driven healthcare 10 Promoting and supporting team-based models of primary care 12 Medicare Locals: reducing health system fragmentation through collaboration 14 Co-production: working together in healthcare 15 Building organisational readiness through people 16 Managing collaboration in partnerships and networks 10 Promoting and supporting teambased models of primary care 14 Co-production: working together in healthcare For editorial content please contact: Sara Byers Media and Communications Officer The Victorian Healthcare Association Level 6, 136 Exhibition Street Melbourne, Victoria 3000 Australia Telephone: Facsimile: vha@vha.org.au Printed on recycled paper using vegetable based inks and environmentally responsible printing methods. The VHA would like to thank member agencies and supporters for supplying many of the photos included in this edition. This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior permission from The Victorian Healthcare Association and inquiries concerning reproduction and rights should be addressed to the editor. The Victorian Healthcare Association Ltd A core responsibility of directorship is to identify the organisation s mission objective and set a strategy to achieve this mission. The Victorian Healthcare Asssociation s recent board self-evaluation survey identified population health approaches to planning and clinical governance as the two most significant training needs of Victorian public healthcare boards. This is entirely appropriate given the strategic responsibility that directorship carries and the risk management obligations associated with implementation of the strategy. The fact that these needs were selfidentified by our survey respondents reflects a developing understanding that the provision of a health service is an increasingly complex business, requiring the coordinated contribution of many players to achieve a successful outcome. In accepting ownership of the organisational strategy, boards are becoming more aware that the limitations of resource availability impact strategic capacity, necessitating ongoing iteration of the business model to remain aligned with the organisation s mission objective. And of course, in a market paradigm characterised by resource scarcity, appropriate management of risk becomes a greater business imperative. As we develop our understanding of what strategy looks like through the lens of a population health approach, we must also formally identify to our community how we are optimally applying scarce resources for their benefit. In moving strategic focus to reflect population health needs, the resources we have available to us will need to be adaptable. The VHA has for many years identified flexible funding models and new approaches to workforce utilisation within our stated strategic priorities. Both are essential to adapting to the changing healthcare needs of our community. Information management and communication technologies that enable care coordination through joined up strategy, and that improve our capacity to overcome adverse outcomes, will also be essential. At this month s VHA policy conference Collaboration: The Key to Better Health presenters will address different approaches to collaboration within our system of health service provision. This program highlights the VHA s belief that directors undertaking a strategy review must explore the extent to which their leadership team is collaborating with other providers to address the overall population health needs of the community they serve. The Victorian Healthcare Association (VHA) is the major peak body representing the interests of the public healthcare sector in Before long, this conversation will become 18 A word from our major sponsor, Health Super Victoria. intuitive to strategic planning exercises at the Our members are public hospitals, rural board table and formal collaborative models will and regional health services, community feature as an outcome of planning activity. health services and aged care facilities. Established since 1938, the VHA promotes This publication is printed using eco-clean print processes. the improvement of health outcomes for Prepared by Anthony Graham and Trevor Carr. Vegetable based inks and recyclable materials are used all Victorians, from the perspective of its where possible. Printed by GEON Brunswick ISO9001 / ISO14001 & AS/NZS 4801 members. 2 3 ANTHONY GRAHAM VHA Chairman The VHA has for many years identified flexible funding models and new approaches to workforce utilisation within our stated strategic priorities. Both are essential to adapting to the changing healthcare needs of our community.

3 Chief Executive s Message Recognising the intrinsic value of collaboration Trends Citizens juries: a growing trend in healthcare TREVOR CARR VHA Chief Executive Collaboration between service providers is not a new theme within the Victorian health system. For over a decade, service providers have worked through Primary Care Partnerships to build their understanding of each other and their consumers. The Health Services Act 1988 requires public health services to establish community advisory committees and there is no doubt that health services in general collaborate with their communities. Rural health services have a long history of collaborating with general practitioners to ensure the sustainable presence of medical support to their urgent care, inpatient and residential care work. Similarly, regional and metropolitan hospital providers collaborate with specialists to ensure that their tertiary work is sustainable. Nearly all public healthcare facilities collaborate with the university and TAFE sector to support practical training for our future workforce. So why is the VHA focusing on collaboration as the theme for this year s policy conference? My answer is that as health service leaders we have tended to collaborate in a way necessary to receive and/or provide information and to sustain a service. That is, collaboration has not been driven by any intrinsic belief in the value of a collaborative model of care. A recent article in the Harvard Business Review examines the evolution of research in relation to human motivation. The article The Unselfish Gene reflects on the work of 18th century economist Adam Smith in identifying that because humans are self-interested and driven by a cost-benefit motivation, their combined actions tend to serve the common good. The article suggests that the way in which this common good is achieved is predetermined to some extent by the rules of play that the participants identify with. It also refers to research by Lee Ross et al, who told one group of participants they would be playing the community game and another group they would play the Wall Street game. In the first group, 70 per cent played cooperatively throughout the experiment. In the second group, 70 per cent didn t cooperate with each other, while 30 per cent started out playing cooperatively but stopped when others didn t respond. The article goes on to state that a consistent and stable body of work tells us that monetary incentives and material rewards can crowd out intrinsic motivations to cooperate and display empathetic behaviour. Nearly all public healthcare facilities collaborate with the university and TAFE sector to support practical training for our future workforce. The Victorian Health Priorities Framework identifies a number of outcomes, principles and reform priorities that will guide policy and funding over the coming decade, all of which have been well-received through metropolitan and rural consultations. The technical papers underpinning the priorities statement articulate significant issues of inequity in relation to resource distribution, service access and health outcomes throughout the state. The yet-to-be-released Victorian Health and Wellbeing Plan will further amplify the need for investment in a range of initiatives aimed at overcoming current deficiencies in upstream determinants of health. This plan will be developed every four years commencing September The Health Capital and Resources Plan (also pending) will afford some understanding to the principles that will underpin the allocation of scarce capital resources, new approaches to delivering care and the resource allocation models that will determine how the budget pie is sliced. Adding further to the collaboration paradigm is the growing expectation of health consumers in relation to patient coproduction. Put simply, a growing number of health service consumers expect to be fully empowered in their receipt of care. The successful implementation of the Victorian Health Priorities Framework (including the supporting plan documents) and the extent to which service providers satisfy health consumerism will necessitate a deeper commitment to collaboration for the good of the overall structure of service delivery throughout Victoria. The change management challenge embedded within the plan will require strength of leadership from the decision-makers within our public health system including parliamentarians, senior bureaucrats, collective boards of directors and chief executives. According to the Harvard Business Review article neuroscience shows that a reward circuit is triggered in our brains when we cooperate with one another. We should all seek to trigger this reward circuit over the coming 12 months, as we start to implement the principles of the Victorian Health Priorities Framework Only then will our maturing capacity for collaboration truly lead to realising the potential of Victoria s public healthcare system for the common good of the community we serve. GAVIN MOONEY The origins of citizens juries In 1954, the World Health Organisation proposed that citizens values should drive health service decision-making. Citizens juries (originally named citizens committees) were founded by the Jefferson Center in Minneapolis, Minnesota, in They were introduced to the UK in 1996 and within five years more than 100 citizens juries had been held there. The Medical Council of Western Australia held Australia s first citizens jury in 2000, facilitated by Professor Gavin Mooney He recommends between 12 and 20 jurors but says 15 is the ideal number, with three or four reserves in case of illness. Jurors should be randomly selected from the electoral roll, not selfselected or recruited through local advertising. Juries must be demographically representative and can be supplemented where necessary by members of minority groups, such as youth or Indigenous communities. The goal is to identify what values should drive social institutions, such as the healthcare system. There should be no template for what will emerge, although most juries reach a broad consensus. Jurors should not make wish lists they must identify service priorities within a limited health budget. I am a health economist who believes very firmly that informed citizens do not have a great enough say in how health services are funded, run and planned. This statement from Professor Gavin Mooney explains precisely why he has pioneered citizens juries within Australia s public health sector. Professor Mooney has worked for 35 years as a health economist in Scotland, Scandinavia, New Zealand, South Africa and Australia. Throughout his career, he has been increasingly concerned by the way economists emphasise individual values over community values. This concern fuels his passionate belief that health services are social institutions that should be based on citizens values, not purely on the needs of consumers, patients and health professionals. In his Handbook on Citizens Juries, Professor Mooney explains that healthcare systems are social institutions, a part of the social fabric and have the capacity to be a major player in influencing the nature of society social institutions which contribute to the health of the population as a whole and not just the individual s health; social institutions, which by being accessible to all, contribute to the idea of living in and helping to build a caring society. Professor Mooney facilitated Australia s first citizens jury in 2000, hosted by the Medical Council of Western Australia. He has since facilitated several juries in Western Australia, South Australia and the Australian Capital Territory. His handbook explains how to bring a random selection of citizens together, give them good information and a chance to quiz experts, and thereafter allow them to discuss and reflect on certain questions, against a background of resource constraints. Professor Mooney says jurors must understand that health dollars are scarce because people s preferences are only truly revealed when they have to identify service priorities within the context of limited resources: If they want more of one thing that means less of something else. He says citizens juries play a crucial role in identifying the overarching values that should drive our healthcare system. That set of values, in my view, has to come from the community This involves using the community voice to establish a set of principles on which policy and actions might be based; such as equity, how important it is and how it might be defined. In Professor Mooney s experience, citizens juries always identify equity as a core value of the health system. In fact, the best definition of equity in healthcare that he has ever seen came from one of his juries: Equal access for equal need, where equality of access means that two or more groups face barriers of the same height and where the judgment of the heights is made by each group for their own group; and where nominally equal benefits may be weighted according to social preferences, such that the benefits to more disadvantaged groups may have a higher weight attached to them than those to the better off. Professor Mooney says there is a growing interest in the use of citizens juries within the Australian health sector. He hopes they will become more commonplace with the introduction of Medicare Locals. citizens juries play a crucial role in identifying the overarching values that should drive our healthcare system. There needs to be some pretty solid consultation with the community on Medicare Locals. I think many of the GP divisions that are likely to become Medicare Locals will see that the best way to do this is to actually get a citizens jury going, he says. I believe very firmly that health services need a major injection of critically-informed citizens values and I know that citizens really can come up with the goods. A Handbook on Citizens Juries can be downloaded at free of charge. 4 5

4 Workforce East Grampians plan to integrate nursing and paramedic skills Workforce Community paramedic program for rural and remote areas nick bush I believe health services and ambulance services both need reform to improve our emergency response to rural Victorians and we have a great opportunity to do that. East Grampians Health Service (EGHS) is seeking to introduce a new training model run by the region s nurses and paramedics. The model is aimed at integrating the skills of doctors, nurses, paramedics and allied health professionals, leading to more collaborative work practices. EGHS is seeking funding from the Victorian Department of Health and support from Ambulance Victoria to research the model, which would see nursing and paramedicine graduates based at Ararat. Chief Executive Nick Bush said this would create the potential for district nursing services at Ararat and Willaura to be upgraded to Remote Area Nurse status, making them first responders in lower priority emergencies. Mr Bush said East Grampians was a potential site for trialling the model in a rural setting, along similar lines to a model currently being trialled in a metropolitan setting at Northern Health. Mr Bush, who attended a recent Ambulance Policy Workshop hosted by the Department of Health, said the model would allow an integrated approach focused predominantly on the outcomes of patient care. He proposed that under the new model, nurses and paramedics would be based at the Ararat site and gain assistance from an integrated team of Ambulance Victoria officers, nurses, doctors, medical students and allied health staff. He said paramedics would be ideal educators for the University of Ballarat Diploma of Nursing students who will undertake training at Ararat from Mr Bush said the paramedic/nursing-led training model could be expanded, with the potential to include role substitution so that nurses, doctors and paramedics all provided emergency response to patients in the local government area around Ararat. There are huge opportunities for teaching, learning and integration between health services and ambulance services. This new model would lead to improved patient care and more effective use of scarce workforce resources, he said. The current model in rural Victoria needs improvement. We have seen from the reports last year that ambulance response times have increased in rural areas. I believe health services and ambulance services both need reform to improve our emergency response to rural Victorians and we have a great opportunity to do that. Ambulance Victoria s General Manager of Regional Services, Associate Professor Tony Walker, said Ambulance Victoria and Northern Health were currently piloting an interprofessional graduate program. This program allows graduates of a joint paramedic and nursing degree to complete an integrated 18-month paramedic and nursing graduate program in an ambulance and hospital environment, he said. EGHS has been in contact with Ambulance Victoria to explore opportunities to participate in a similar program. We have indicated we are happy to discuss this with them further once the current pilot program has been evaluated. Associate Professor Walker said Ambulance Victoria had introduced community emergency response teams in 29 communities and provided specialised emergency care training to more than 60 remote area nurses in 15 bush nursing centres, enabling them to co-respond with an ambulance to emergencies in their communities. Associate Professor Walker said Ambulance Victoria had recruited 224 new paramedics to work in country Victoria over the past 12 months in addition to eight new MICA single responder units and 19 non-emergency patient transport shifts to improve service delivery and reduce paramedic fatigue. This includes an additional seven paramedics in Ararat and an additional 12 for Stawell by the end of this year, he said. We have consolidated our call-taking and dispatch into a single rural communications centre in Ballarat, which provides more consistent services and access to a 24-hour senior MICA paramedic who provides clinical advice. PETER O MEARA La Trobe University Professor of Rural and Regional Paramedicine, Professor Peter O Meara, has welcomed Western Australia s statewide community paramedic program, saying it is an overdue step in the advancement of emergency health service models in Australia. The WA Government and St John Ambulance WA are implementing the program in rural and regional areas, following a two-year review of ambulance services. So far, 12 community paramedics have joined WA s regional workforce, out of 39 to be recruited. The community paramedic role goes beyond the core business of transporting sick and injured patients, providing support to local ambulance service volunteers through recruitment, training and mentoring activities. Under the WA program, community paramedics are trained by professional paramedics to respond to emergencies within their own communities. Professor O Meara welcomed the initiative as an overdue step beyond small trials that have been underway throughout Australia for a number of years. Meeting and office facilities for member agencies Comfortable facilities are available for member agencies at our Exhibition Street premises in Melbourne s CBD. These facilities are available to members, without charge, providing you with a base in the CBD for meetings, forums, interviews or catching up on work. Mainstreaming innovative changes to emergency health service models is a very important step for the paramedic profession and for rural and remote communities, he said. It will see a significant increase in the professional profile of paramedics. Professor O Meara s own research into community paramedic roles has shown that highly skilled paramedics have a very positive impact on the health of rural and remote communities, which would otherwise rely on volunteer ambulance officers. He said the community paramedic role encompassed the core activities of rural community engagement, emergency response, scope of practice extension and primary healthcare. It is important to appreciate that the introduction of community paramedic models needs to be based on the values, priorities and capacity of the communities they serve. Ambulance services should clearly define community interaction goals and ensure that paramedics have the appropriate leadership and networking skills. Professor O Meara said the community paramedic model had the capacity to facilitate higher quality and more equitable emergency healthcare in rural and remote areas. Allowing a broader role for paramedics to apply the clinical and other specialist capabilities that they already possess through their professional experience will extend the capacities of ambulance service resources. He said a robust education system that gives paramedics broad knowledge, understanding, skills and professional attitudes that allow them to operate as independent practitioners was critical to the success and sustainability of the community paramedic model. Make your membership count Conference facilities VHA s multifunctional facilities can cater for meetings for groups of between two and 50 in both boardroom and theatrestyle configurations. Videoconferencing, teleconferencing, whiteboards and AV facilities are available on request. Fruit, biscuits, water, tea and coffee can be provided for meetings, on request. A list of catering options is also available. La Trobe University s new combined Bachelor of Health Sciences/Master of Paramedic Practice aims to give community paramedics a broad education that encompasses health and emergency service planning and primary healthcare skills, such as health education and screening. For these roles to succeed, paramedics require enhanced knowledge and understanding of rural health issues as well as having the skills to deal with specific ambulance service issues, such as the leadership, management and support of volunteers, Professor O Meara said. Apart from advanced life support knowledge and skills, in which they are already trained, community paramedics appointed to small rural communities need a broad range of knowledge and skills that enable them to make positive contributions to patient care and community health. Ambulance Victoria s General Manager of Regional Services, Associate Professor Tony Walker, said Victoria was the first state in Australia to introduce community paramedics, who have been operating in Mallacoota and Omeo in south-east Victoria since These paramedics support local ambulance volunteers and health practitioners by providing community health promotion and education programs and advanced life support care, Associate Professor Walker said. Our current focus is on increasing traditional paramedic numbers to improve our emergency response, as identified in the recent Auditor General s report into ambulance services. At this stage we have no plans to expand the community paramedic program in Victoria. 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5 Workforce Ambulance and health service collaboration improves rural access Research New research alliance to explore community-driven healthcare We conducted workshops with the nurses and the paramedics so they started communicating better and working together. A New South Wales ambulance integration project found that paramedics and health services could collaborate to improve access to healthcare in isolated communities. The project Collaboration of the delivery of rural health services between NSW Ambulance and Greater Southern Area Health Services sought to formalise a range of existing paramedic integration activities, trial new activities, provide training and recognition for staff involved and lead to research of the project outcomes. It was run in 2007 by Manager Planning and Community Participation at the former Greater Southern Area Health Service, Bob Neumayer, and Manager Clinical Professional Development at the Ambulance Service of NSW, Graeme Malone. They hoped the project would increase access to services for the communities involved, while improving staff satisfaction as a result of enhanced work roles and increased skills. Integration activities included paramedics monitoring infusion pump medications during inter-facility transfer, doing 12-lead ECG reporting and providing overall support to registered nurses in emergency departments. Community health-based integration activities included home wellness checks, such as medication and BP checks, wound dressings and shared training. Some of the findings included: paramedics could participate more in emergency departments, communitybased care, home health visits and training opportunities with health service staff without compromising their core function; reluctance to participate from some ambulance paramedics and health staff at the beginning of the project was largely eliminated once they became involved in specific activities; most paramedics said they would like to continue their involvement in the project with better support; standardisation of equipment, protocols and procedures were needed across all sites so paramedics fully understood what activities they were authorised to perform while supporting emergency department staff; stronger communication links were needed between community health team leaders, nurses and paramedics; and specific training programs needed to be established to upskill all participants in the integration project. Mr Neumayer, also the former Head of Charles Sturt University s School of Community Health, said the project changed a perception that paramedics were purely emergency workers. Initially, they did not see themselves as health people more that they were frontline, prehospital emergency and transport officers. We had cultures that needed to change on both the community health side and the paramedic side, he said. We conducted workshops with the nurses and the paramedics so they started communicating better and working together. Our paramedics began to realise there was so much more they could be involved in from a rural health service perspective. Mr Malone said the Ambulance Service of NSW was very supportive of rural areas. This project is an example of how we are implementing processes and procedures that contribute to the clinical skills of paramedics, beyond the traditional paradigm of just doing emergency medicine, to more broadly contributing to health services in rural and remote communities, he said. Jane Farmer A developing research alliance between the Rural Health Schools of La Trobe, Monash, Melbourne and Charles Sturt universities aims to establish an international research group on community-driven healthcare based in Victoria. The collaboration has applied for funding for a centre of research excellence through the Australian Primary Healthcare Research Institute, which funds and coordinates innovative research in primary healthcare and system improvement (see Health Matters, April 2011). The group is keen to hear from health services, communities, academics and peak body representatives who might be interested in collaborating in this research partnership. Its aim is to establish evidence for citizen-driven integrated service planning, implementation and production. There is little international systematic evidence on how to best integrate consumers into healthcare design. Anyone who starts working with communities to involve them in service design pretty soon encounters issues like inclusion how to include everyone, the extent to which it matters if you can t, and the legitimacy of decisions made by only a portion of the community. Another issue is how to move engagement beyond one-off interventions. Communities are not static entities their service design will adapt and develop so what sustainable models are there for ongoing community involvement? Scaling up participation to get communities working together to design innovative health delivery models across regions is another significant issue. While many health services and agencies have tackled community participation, evidence has not been systematically collected. Many countries are stuck on how to take community governance in health forward, feeling intuitively that it is a good thing but being concerned about the problems that could arise from the perception of handing decisions over to citizens and communities. Consideration of the role of communities and how governance mechanisms might work could involve exploring international models, such as deliberative decision-making from South America or co-operative enterprise in rural Spain. While international policy urges health services to involve citizens and communities, there are significant gaps in the evidence on how to achieve locally-appropriate, community-designed and co-produced integrated primary healthcare service models in under-serviced communities. As is often the case, a concerted effort to bring together existing evidence might see solutions from unlikely places. We want to build a collaborative research effort that will find out how communities can inclusively plan services locally and over wider areas, overcome systemic barriers and produce coordinated teamwork. We hypothesise that communities will produce better health outcomes and more appropriate use of health services, as deep knowledge is produced from involvement. The ethos at the heart of this approach is co-production, whereby public services incorporate communities into the production of services (see separate story page 14). Coproduction identifies the perspective of how the user and stakeholder see and use the system as the missing link in health reform. A major aim of reform is ensuring local communities have health services that better respond to their needs and priorities. Healthcare policy and macro-level structure can affect the degree to which health services can be locally responsive. A one-size-fits-all approach does not address local priorities nor make optimal use of scarce local resources, including community members and a range of service practitioners. Our research will test the theory that by making local users and staff central and integrating components of planning, design, implementation and production, improved health services, health services literacy and, consequently, health, wellbeing and more responsible use of services will result. Bringing knowledge of health services to local people and involving them in basic services could also develop their aspirations to become qualified health and social services workers. Further, if consumers have access to knowledge from inside the healthcare system as opposed to the superficial information from the media, they can take responsibility and help to drive systemic change. This whole approach is predicated on developing healthcare users as intelligent, responsible, enabled contributors to health who have a role in driving health and health services. The research alliance will involve regional campuses, including those of the four collaborating universities at Bendigo, Mildura, Albury-Wodonga, Shepparton, Ballarat and Moe. The university partners have metropolitan and regional campuses, so there is potential for research comparisons and capacitybuilding through partnerships between rural-metro academic staff, students, health services and communities. Systematic evidence about the processes and outcomes of involving urban and suburban communities in healthcare planning and design also remains unexplored. Given our regional locations, our priority is working closely with local regional health services to collaborate on capacity-building and partnering to make rural services better places to recruit and retain staff. The research we want to conduct features collaboration as its underpinning philosophy, as it follows the principles of participatory research where all stakeholders, from citizens to policy, are engaged and that engagement facilitates knowledge translation. Professor Jane Farmer is Head of La Trobe Rural Health School. 8 9

6 Workforce LUCIO NACCARELLA Promoting and supporting team-based models of primary care A cacophony of terms, concepts and definitions of team-based models exist depending on whose perspective is given policymakers, practitioners or academics. There is recognition of the need to prepare, support and sustain the primary care workforce to provide care in the right place at the right time. Internationally, team-based models of primary care workforce have emerged to address multiple health system challenges. These challenges include: escalating healthcare costs; rising demands from an ageing population; patients increasingly presenting for primary care with chronic, complex and multi-morbidity; increasingly complex and fragmented health systems; growing expectations to support and engage people in their own care; and inadequate access to primary care due to workforce shortages and mal-distribution. In 2010, I led two key research efforts designed to inform team-based models of care, including a literature review funded by the Australian Primary Health Care Research Institute 1 and a review of international papers for the International Medical Workforce Collaborative (IMWC) 2 conference. The literature review, entitled Incentives for Primary Health Care (PHC) Team Service Provision, revealed: there is no agreed upon definition of teamwork or incentives to enable and support teamwork to exist within the PHC setting limited empirical evidence exists on incentives to promote teamwork within PHC, or on how policy changes influence teamwork in PHC practice-level payments can enhance approaches for teamwork but they do not guarantee that teamwork will be provided, and limited evidence exists as to the effect of specific funding parameters on teamwork regional-level PHC organisations can enable and support teamwork but funding, organisational and regulatory systems need to align in order for this to happen inter-professional education and learning (IPE/L) can encourage teamwork but does not automatically result in teamwork because it is a means to an end, not an end in itself workforce reforms need to facilitate teamwork by providing PHC team members with opportunities for career development, IPE/L, autonomy, leadership and financial rewards Three policy options emerged from the literature review, including the need to: prepare the future PHC workforce to learn and work together support the existing PHC workforce to learn and work together sustain an evidence-based PHC workforce to learn and work together My review of papers from the United States, United Kingdom, Canada and Australia for the IMWC conference was entitled Working Together Team-based Models of Primary Medical Care: What s Working in Complex Care Management 3. It revealed that all four countries are in the midst of health system reform processes and reform fatigue. The review established that there is an emphasis on primary care system orientation to address health system problems, and a focus on access, equity, and supporting and strengthening a multidisciplinary trained primary care workforce. All four countries suffer from islands of innovation syndrome with limited evaluative implementation evidence to inform new models of primary care workforce. A cacophony of terms, concepts and definitions of team-based models exist depending on whose perspective is given policymakers, practitioners or academics. There is recognition of the need to prepare, support and sustain the primary care workforce to provide care in the right place at the right time. However, there is also an underemphasis of the importance of workforce planning to support team-based models of primary care for people with complex care needs. My review and synthesis of Australian teambased models of primary care revealed that interdependent contextual factors and subsequent policy levers can influence how the primary medical care workforce can be supported to work in team-based approaches. These factors include: the existence of practice-level, team-based payment systems having expanded workforce roles and skills mix having a practice organisational capacity to support team-based CCM ensuring that all future policy reforms and initiatives have funded evaluation plans that use evidence-based and team-based care evaluative frameworks, methodologies and tools Witness experts Leading experts. Innovative programs. Extraordinary experiences. The Melbourne Law Masters. Enrolling now. Based on these two research efforts, I have concluded that four areas must be addressed in order to provide Australians with access to cost-effective, community team-based primary care, including the need for: policy levers to prepare, support and sustain the primary care workforce to learn and work together evaluative implementation evidence, as well as performance management, research and evaluation indicative evidence for inter-professional education, training, and practice and regulatory strategies improved workforce planning to support team-based models of primary care for people with complex care needs In summary, this means getting the right people in the right roles, with the right skills and competencies, in the right place at the right time. Dr Lucio Naccarella PhD is a Senior Research Fellow at The Australian Health Workforce Institute at The University of Melbourne and with General Practice Victoria. 1 of20successful20primary20health20care/ Incentives_policy_options.pdf 2 International Medical Workforce Collaborative rcpsc.medical.org/publicpolicy/imwc/conference12.php 3 Naccarella, L., LeBoutillier, S., Mulcahy, A., Nasmith, L., Creede, C., Kupka, S., Michener, L., Berkowitz, B., Oliveira, J., Cook, J., Sutton, M. Theme 4: Working together Team-based Models of Primary Medical Care: What s working in Complex Care Management? Case Studies from Four Countries. org/publicpolicy/imwc/2010-imwc12/imwcteambasedmodelspaper2apri2010.pdf

7 Federal Reform Medicare Locals: reducing health system fragmentation through collaboration The role of independent community health services and local government authorities in primary healthcare provision in Victoria requires a different form of collaborative effort. JOHN RASA Medicare Locals have great potential to reduce the current fragmentation in the Australian health system by providing strong local platforms for integration and coordination between diverse service providers. There are many who hope that Medicare Locals will have both the capacity to deliver better integrated services for those suffering chronic and complex conditions and the ability to reduce demand on a system which is overburdened by the impact of preventable diseases. There is a Commonwealth expectation that Medicare Locals will achieve better coordination of general practice and other primary healthcare services, while identifying and filling gaps in service provision. Medicare Locals are expected to play a key role in improving access to after-hours care, respond to chronic disease prevention and management, and implement new mental health initiatives aimed at providing services to those most at risk of mental illness. These initiatives, in turn, will need to be managed across the public and private healthcare sectors requiring significant planning, influencing and procurement skills of primary healthcare managers. Victoria prides itself on a strong history of inter-sectoral collaboration and on its welldeveloped, partnership-driven primary and community health sector. However, the recent Invitation to Apply process for Medicare Locals tested the strength of existing partnerships formed during the establishment of Primary Care Partnerships a decade ago. Many divisions and their partners rose to this challenge, despite additional complications in Victoria caused by ongoing uncertainty over the final boundaries for Medicare Locals. On 1 July 2011, the initial four Medicare Locals in Victoria commenced on the road to improved integration of health services to four quite diverse populations in Barwon, Northern Melbourne, Inner North West Melbourne and Inner East Melbourne. The remaining 13 Victorian Medicare Locals will be announced later this year. In July, the Federal Government also invited the Australian General Practice Network [AGPN] to form the new National Organisation for Medicare Locals, recognising that the AGPN is well-placed to facilitate collaboration with key partner organisations at the national level to help drive primary healthcare reforms. The Government s extension of funding for the Divisions of General Practice State-Based Organisations [SBOs] until 31 December 2012 is also a welcome decision, which will provide time for the current SBOs and the AGPN to negotiate the future form of the national body and how to satisfy state functions. The key question for Victoria in the development of a National Organisation for Medicare Locals is what role the AGPN sees for organisations trying to perform state-based functions in what appears to be strained commonwealth-state relations. This situation has developed from ongoing tensions over the system manager role in national health reform between the Commonwealth and the states, particularly Victoria. At both the April 2010 and February 2011 COAG meetings, the Commonwealth made significant concessions to the states and territories in order to maintain their system manager roles of the hospital system. The management role of primary healthcare services remains contested and in Victoria, with its complex primary and community health service delivery system, this ongoing tension will, in turn, influence the future form of a state-based organisation to support Medicare Locals. Better management at the seams of healthcare will require health service managers to take a more external view of where their organisations sit in the broader health system context. GPV provides ongoing support to the AGPN to achieve better integration of health services in the quite complex environment of Victoria but recognises it will need to support a much broader membership of health service providers in the future. Victoria has a health system environment that is highly decentralised. It has a long history of community engagement and community health service providers collaborating around preventing avoidable hospital admissions, which is quite different from other state governments. But more needs to be done, including taking a whole-of-health-system perspective that considers the private health sector. A planned national body will provide the policy and program innovation from a national perspective to progress primary healthcare across Australia. It is also expected to provide the necessary coordinated effort with other peak national health bodies, including those from the Indigenous sector, consumers, aged care sector and other primary healthcare providers such as allied health groups, all of whom play a key role in the delivery and improvement of general practice and primary healthcare across Australia. GPV has a strong history of collaborative effort with state-based NGOs, who are unlikely to have a Medicare Local presence. While the national body will enable greater efficiency and the streamlining of primary healthcare programs, it will also need to focus on achieving effectiveness in primary healthcare service delivery by collaborating with state governments over health system management design, innovation and change management. The role of independent community health services and local government authorities in primary healthcare provision in Victoria requires a different form of collaborative effort. Here, with greater accountability in our health system design, comes the potential for greater system fragmentation. A common and understandable perspective is: I only need to worry about my patch to demonstrate I can manage effectively amongst health service managers. This is prevalent in all health and aged care sectors struggling with tough budgets. However, this is not the expectation of patients and health consumers. Patients struggle to find the right service at the right time, or once they have seen their GP, the next step in their care does not flow seamlessly. Better management at the seams of healthcare will require health service managers to take a more external view of where their organisations sit in the broader health system context. Similarly, the Divisions of General Practice and the AGPN have been well placed in the development of a more coordinated primary care system incorporating greater nursing support, but they now need to change in organisational form to help create new primary healthcare organisations called Medicare Locals, with expanded allied health membership. General practices and community health services will need to partner more closely to provide a more coordinated response to patients with chronic and complex care conditions, either living at home or being discharged from acute hospitals. Aged care will need to partner more effectively with the primary healthcare sector in preventing unnecessary hospital attendances. The establishment of Medicare Locals is aimed at shifting the focus of the Australian health system towards primary healthcare and local decision-making so that communities can reconnect with the health system and with the services they seek. Medicare Locals will have responsibility for planning, health improvement and service delivery procurement. They will need to foster new partnerships and alliances to achieve these ends. Significant networking and influencing skills will be required to enable power sharing when it comes to planning and prioritisation of services. In a financially constrained environment, where health workforce issues still loom large in rural and outer-metropolitan areas, meeting both consumer and government expectations will be challenging. The Commonwealth has given Medicare Locals a mandate that includes a much broader scope of activity and primary healthcare, in relation to integration, than is currently fulfilled by General Practice Networks (GPNs). This mandate will see Medicare Locals take on increasing responsibilities for population health planning, identification of gaps in services, increased fund holding, development of models of care to best meet service gaps, commissioning and ensuring delivery of services, and monitoring and reporting on performance. Medicare Locals will not be delivering services except where there is market failure. To achieve the objective of developing a better integrated health system, where consumers and the community experience a more seamless service from multiple providers, it will be essential to put in place and demonstrate strong linkages and engagement with other pillars of the health system, including the hospital sector (Local Hospital Networks) and the aged care sector. Medicare Locals will also need to meaningfully engage with private hospitals, mental health service providers, drug and alcohol services, private allied health services and a wide range of privately funded and philanthropic organisations involved in both direct and indirect service provision. With 86 Local Hospital Networks and 17 Medicare Locals planned for Victoria, integration will be a challenging, though not impossible, task. Again, forming solid collaborative partnerships between the acute, primary health and aged care sectors is the key but will require fine-tuning of the interpersonal skills of our health service managers. However, Victoria is building on a solid base that needs further investment to reach its full potential. In its efforts to better integrate the health system, the Commonwealth has made it clear that it is looking for improved demonstrated performance from the primary healthcare sector and Medicare Locals. The necessary transparency is expected to be delivered through a performance and accountability framework that includes key performance measures for Healthy Community Reports, which will be made publicly available and provide regular updates on the performance of Medicare Locals. The framework has been drafted and is awaiting final approval. It is expected to bring an increased focus on achieving results and demonstrating the difference that the primary health sector can make to the health and wellbeing of Australians. This will be an additional challenge for a sector that has been better at measuring activity than health outcomes. It is only hoped that the Commonwealth is realistic in its expectations of improved performance in this area. The focus of Medicare Locals on local decision-making and enhanced primary healthcare and the accompanying reforms to the hospital and aged care sectors offers opportunities for collaboration between GP network members, hospitals and community health services to develop models of integration across the broader primary health, acute and social care sectors. Indeed, the first tranche of Medicare Locals may be well-placed to demonstrate the necessary conditions required to achieve greater collaboration between health service providers and to thereby increase effectiveness in healthcare delivery. John Rasa is CEO of General Practice Victoria

8 Workforce Co-production: working together in healthcare VHA Award Sponsor Building organisational readiness through people Shifting the power in healthcare to create a reciprocal and equal relationship between patient and provider has the potential to transform our approach to delivering healthcare services and produce better health outcomes. Working together to get things done is the underlying principle of co-production. 1 Co-production is also about patients/clients as active participants rather than passive consumers; it promotes collaborative rather than paternalistic relationships between healthcare providers and patients and puts the focus on delivery of outcomes rather than just services. The concept of co-production came from Nobel prize-winning economist Elinor Ostrom in the 1970s. Through her research, she found that involvement by the recipients of services led to improved public goods at reduced public expense, which in turn strengthened communities. She called this co-production and defined it as the process through which inputs used to produce a good or service is contributed by individuals who are not in the same organisation. This observation was further developed by Washington civil rights lawyer Professor Edgar Cahn, who said co-production worked on two levels: individuals, families and communities working together with paid staff and professionals to achieve desired outcomes; and funded resources and services working with individuals, family and community. According to Professor Cahn, these two levels set up a special kind of partnership between agencies and their communities, creating a win-win situation for all involved. He said that in order to bring people together in equal partnership for decisionmaking and service delivery, there had to be greater recognition of undervalued human resources. For co-production to occur healthcare providers need to shift from being fixers who focus on problems, to enablers who focus on abilities and encourage patients to use them. Former head of the Centre for Clinical Management Development at Durham University, Pieter Degeling believes that the key to encouraging patient co-production lies in recognition by all parties (service providers, funders and patients) of the multiple levels within the healthcare system. For example, service models and funding mechanisms will have to change to promote and sustain effective co-production approaches: People s propensity to be involved in their health depends on the GP clinic set-up. The more consumers feel they are having an effect, the more likely they will actively engage in producing their own health. Mr Degeling notes that providers will need support to change their models of practice. He says new funding models and data support systems can encourage GPs to change. For the GP to stem the flow of patient readmissions, it will require a massive change to their practice; they will not look the same. However, to remain financially viable a different type of funding system is needed. For example, the GPs can help save the acute system a lot of money if they can reduce the frequency of acute exacerbations of long-term conditions with patient coproduction, but the savings are not passed on to the GP, says Mr Degeling. The concept of coproduction came from Nobel prize-winning economist Elinor Ostrom in the 1970s. Through her research, she found that involvement by the recipients of services led to improved public goods at reduced public expense, which in turn strengthened communities. We need to look at things differently to really make a change. And the same can be said for the full range of public human services in the community. Organisations like the GP clinics and community health centres that co-produce with clients, their families and communities, do not all look the same but they will have in place similar processes where: patients/clients are treated as assets, not burdens on an overstretched system patients/clients use peer support networks for transferring knowledge and capabilities services are reconfigured to reduce the distinction between producers and consumers public service agencies become catalysts and facilitators rather than simply providers self-organisation is encouraged rather than direction from above; and strategies are developed to build the capacity of local communities Importantly, the aim of co-production is not just about consultation or participation; it is to encourage people to use the human skills and experience they have to help deliver public or voluntary services. 1 Right Here, Right Now There is transformational change occurring in our healthcare systems. The pace is accelerated, the change is global and leaders who can deliver on vision are key to success. Hardy Group International (HGI) a specialist in health and public sector talent management and leadership solutions has a focus on helping build a sustainable, fit-for-purpose workforce to meet the challenges of shaping and providing 21st century healthcare. Delivering transformational reform requires skilled and agile leaders operating within a governance framework and an organisational culture that supports flexibility and learning. HGI believes there are four key indicators for success in supporting organisational preparedness and agility talent acquisition, management, development and retention. Our business is about leadership and Undertake CEO selection and performance evaluation. Lead and monitor corporate culture. Formulate strategy appropriate to the population health needs of the community being served. Ensure that effective healthcare governance processes are in place and equally emphasise corporate and clinical governanceresponsibilities. Develop a risk management and quality framework appropriate to the delivering results through helping you secure, grow and nurture your best people. HGI s integrated leadership and systems solutions include: search and selection; talent and succession management; innovative problem solving; and learning strategies that include virtual and online approaches. Our solutions are results-focused, supported by a range of objective tools and underpinned by principles of accelerated, real-time action learning, value, rigour and global leadership networks that support success. HGI is working with the Australian Centre for Healthcare Governance to pilot a chairs round table next month. Chairs from Victorian public health services will learn from each other as they explore issues they are managing in complete confidence. HGI is also the proud sponsor of this year s Victorian Healthcare Association (VHA) Annual Australian Centre for Healthcare Governance A ViCtOriAn HEALtHCArE AssOCiAtiOn initiative The Australian Centre for Healthcare Governance (ACHG) can help you: For information please contact: Trevor Carr Chief Executive trevor.carr@vha.org.au Alison Brown Clinical Governance Consultant achg@healthcaregovernance.org.au activities of the organisation. Contribute to big picture policy formation. Create networking opportunities with peers through director round tables and other professional development activities. Keep up to date with research of relevance to healthcare governance. PHOnE Australian Centre for Healthcare Governance Level 6, 136 Exhibition street Melbourne Award, which recognises a member agency, or agencies, that exemplify the workforce and service collaboration necessary for 21st century healthcare. CEO of HGI Frank Tracey will be on the judging panel and will present the winner s trophy at the VHA s annual policy conference Collaboration: The Key to Better Health, being held in Melbourne this month. More information on the chairs round table will be available at the conference. there are four key indicators for success in supporting organisational preparedness and agility talent acquisition, management,development and retention

9 Federal Reform Managing collaboration in partnerships and networks DAVID BRIGGS The achievement of novel organisational developments 1 may be the ultimate outcome of the current national health reforms. Internationally since the mid 1990s state-level policies to reform national health systems have sought to modernise by focusing on new forms of local resource utilisation and collaboration ( 1 p166). Reform has become a constant in healthcare, but to be effective it needs to be focused on care and service delivery that puts the patient and community experience of healthcare ahead of considerations about structure. It should be seen as evolving a transition with continuous refinement and not a one-off solution. Primary health care (PHC) reforms to establish Medicare Locals may provide the opportunity to take that evolutionary transitional approach towards novel organisational developments. Collaborative approaches are seen as being essential where rapid, structural, and probably irreversible changes are generated by powerful political and economic forces 2. The same approach in the existing public health/acute care sector may initially prove a step too far for the recently-established Local Health Networks, given that they are creatures of highly controlled, systemised state health services. Institutional theory suggests that those types of organisations may be internally focused on regulatory compliance, accreditation and the implementation of top-down policy to ensure that they remain credible, rather than focused on new ways to deliver health services. The exception might well be Victoria. The scale of organisations and the continued engagement of stakeholders and communities in more localised governance structures, in my view, may well provide an opportunity for more collaborative approaches. In contrast, PHC in Australia has no overarching institutional framework and is mostly delivered through what might best be described as a small business model of independent providers, with some corporatised private providers and a diverse group of nongovernment organisations (NGOs). Interestingly, the mix of PHC provision in Australia bears a number of similarities to the Canadian PHC context. A recent policy analysis of PHC reform in Canada suggests that transformation can be achieved voluntarily in a pluralistic system of healthcare delivery that is incremental and has strong government and professional leaders ( 3 p282) in support. For those of us involved in the establishment of Medicare Locals, the Canadian experience is heartening news. Divisions of General Practice, first established nearly two decades ago, were an initial step to establishing an overarching PHC framework. To their credit, they have extended the focus from general practice to a broader concept of PHC and towards greater community engagement, which is a fundamental underlying principle of PHC. Importantly, divisions have become expert at managing contracted services from multiple providers and collaborating with partners, stakeholders and communities. The company structure and governance, independent of direct bureaucratic control, makes the funding and operation of divisions more transparent and manageable. Medicare Locals have the challenge of building on these approaches. They will, by necessity, become more complex in their structures and processes ( 1 p166). The range of stakeholders will increase exponentially, there will be multiplicity in funding and accountability arrangements, clinical and corporate governance will be more sophisticated and methods of managing will need to be different 1. Three existing Divisions of General Practice made a successful submission to establish what will be the New England Medicare Local (NEML) based in northern inland NSW. We were mindful that a largely decentralised structure would be required to establish a greater focus on PHC in a rural area larger than the land mass of Tasmania, which has relatively few large population centres and many smaller rural communities. The NEML had to be capable of operating through dispersed networks of mostly small organisations and individual PHC providers, who would have to collaborate while being geographically hours apart. We proposed a structure that focuses on clinical governance encompassing the full spectrum of quality, safety, accreditation and credentialing, with an emphasis on education and professional development. In addition, we focused on population health research and planning, community engagement and corporate services emphasising contract management and compliance. Service delivery and elements of those core functions will mostly be administered through three geographically defined networks, based on the reach of the pre-existing GP divisions. In taking this approach we avoided the bureaucratic urge to centralise and rationalise for the sake of often claimed, but not often achieved, efficiency ahead of effectiveness. There is significant research literature suggesting that human behaviour and professional subcultures are central to defining the success, or otherwise, of policy implementation. International experience in PHC suggests that implementing the policy approaches described above through Medicare Locals may be difficult. This is because operational managers and their bureaucratic masters are conditioned by their experience of market or institutionally orientated systems, where particular political or professional interests are dominant ( 1 p173). Note well that community interest does not even rate in that quotation! This same international research suggests that participation, fairness of benefit and equality of respect are essential in promoting parity in primary care relationships 1. Those aspects of parity suggest a human dimension to health services. Healthcare is delivered through highly professionalised, complex and contextualised organisations but is essentially a people-to-people human service business, so the context should be people-centred. Therefore, an understanding of human behavior, both organisationally and culturally, should be extremely important. In particular, the influence that professional sub-cultures bring to healthcare and its management should be well understood by those who develop public policy and by the health managers who implement that policy. There is significant research literature suggesting that human behaviour and professional sub-cultures are central to defining the success, or otherwise, of policy implementation. Therefore, understanding the attitudes and values (called archetypes in the literature) of those involved in an organisation is fundamental to understanding their influence on organisational change 4-5. Unfortunately, the emphasis of policy makers and reformers is overly focused on organisational structures, processes and control. The consequences of that approach have been seen in a number of formal inquiries into large state-based health systems 6-8. In addition to acquiring a greater understanding of these issues, the national health reforms will require greater emphasis on working within networks of practice to deliver more integrated care across the continuum and existing industry sectors. Importantly, given the diverse and multiple providers and geographic considerations in regional and rural PHC, we will need to become more familiar with concepts of managing and delivering services based on distributed networks of practice 9. The benefits of collaboration are said to be greatest when it provides for: effective management, parity and participation of stakeholders increasing patient and community engagement interprofessional education and representation multiplicity of funding and accountability diversification of NGO roles These themes were seen as important in translating policy formation into implementation 1. Collaboration also allows increased focus on shared vision, values and developing a more consistent culture across diverse groups, identifying synergies, aligning strategy and emphasising relationship management 2. The context described above places health managers within a complex professionally dominated, politically driven system that is experiencing constant change ( 10 p16). The reform process increases the risk of a loss of expertise in health policy, leadership and management skills It also requires us to think through the potential for new ways of organising, managing and delivering services. The 2008 declaration published by the Society for Health Administration Programs in Education (SHAPE) and subsequently endorsed by the Australasian College of Health Service Management (ACHSM) calls for informed debate on health reform. The SHAPE declaration suggests reform should focus on health outcomes, the needs of communities and frameworks of responsibility and cooperation. The structure should follow, allowing for diversity of need, demonstrating good governance, management and the effective engagement of structural interests. The SHAPE declaration suggests reform should be transitional and that well qualified and competent management (should be) engaged at all levels of reform and healthcare delivery ( 13 p11). In addressing the importance of health managers in delivering effective health reform, SHAPE suggests that health service managers should: be trained and experienced to lead and manage in a range of differing health system and organisational arrangements possess a deep contextual understanding of health systems, public policy, professional cultures and politics have competency in organisational sensemaking as negotiators of meaning, active participants, constructors, organisers and persuaders within health systems be drawn from a range of backgrounds, including those with clinical and nonclinical experience and qualifications who can demonstrate broad contextual health knowledge that demonstrates more than one logic understand how clinical work should be structured and managed and work actively with clinicians and others to deliver coherent, well-managed health services ( 10 p12) As reform is a continuous process, we need to ensure that our managers, governance arrangements and organisations are adaptive, capable of transition and well-engaged with the communities and populations they are meant to serve. Dr David Briggs is the Coordinator Health Management Programs, School of Health, University of New England, the Editor Asia Pacific Journal of Health Management, National President of SHAPE, Director of the Northwest Slopes Division of General Practice and Chair of the New England Medicare Local Steering Committee. References 1 Meads G, Wild A, Griffith F, Iwami M, Moore P (2006). The management of new primary care organizations: an international perspective. Health Services Management Research 19: Austin JE, The collaboration challenge: how Nonprofits and Businesses succeed through strategic alliances. Jossey-Bass Publishers. San Francisco Hutchison B, Levesque J F, Strumpf E, Coyle N (2011). Primary Health Care in Canada: Systems in Motion. The Millbank Quarterly 89 (2): Greenwood R & Hinings, CR. (1993). Understanding strategic change: The contribution of archetypes. Academy of Management Journal, vol. 36, no. 5, pp Brock D. (2006). The changing professional organisation: A review of competing archetypes. International Journal of Management Reviews, vol. 8, no.3, pp Davies G. Hospitals Commission of Inquiry Report. Brisbane: Queensland Health; Forster P. Queensland health system review. Brisbane: Independent Review; Special Commission of Inquiry into Acute Care Services in New South Wales Hospitals; Hustad E. (2007). A Conceptual Framework for Knowledge Integration in Distributed Networks of Practice. Proceedings of the 40th Hawaii International Conference on Systems Sciences; Briggs DS. The lived experience of health services managers [Dissertation]. University of New England Armidale; Liang, Z.M., Short, S. D., Howard, P.F. & Brown, C.R. 2006, Centralised control and devolved responsibilities: Personal experiences of senior health executives on the implementation of the area health management model in New South Wales, Asia Pacific Journal of Health Management, vol. 1, no. 2, pp Isouard, G National Health Reform Success: It s all about Leadership and Management, Australian Quarterly, No. 82, pp Briggs DS. (2008). Shape Declaration on the Organization and Management of Health Services: a call for informed public debate. Asia Pacific Journal of Health Management 3(2):

10 VHA Major Sponsor A great result from Health Super chris deakin We are pleased to report that the Victorian Healthcare Association s major supporter, Health Super, was the top performing superannuation fund as ranked by SuperRatings for the 2010/2011 financial year 1. Health Super s performance was strong for the second year in a row, with the Long-Term Growth investment option ranked number 1 out of 92 funds and the Medium-Term Growth investment option ranked number 1 out of 122 funds. Market Report by Health Super Despite periods of weakness, financial markets performed strongly during the 2010/2011 financial year. Markets were supported by improved economic growth and central banks across the world keeping interest rates at historically low levels. However, ongoing concerns over sovereign debt problems in Europe, the United States budget deficit and the earthquake in Japan all led to periods of volatility. Share markets were particularly strong in the 2010/2011 financial year, with both Australian and international markets producing double digit returns. Returns for Australian investors in international shares were reduced by the strong Australian dollar, which hit an all time high against a number of currencies. Australia s link to China and its comparatively high interest rates have been a key factor in the strength of the Australian dollar. Fixed interest markets produced solid single digit returns over the financial year as central banks around the world continued to keep interest rates low. The Reserve Bank of Australia has been one of the few exceptions, with the Official Cash Rate (OCR) of 4.75 per cent being amongst the highest of developed nations globally. Investment Returns for Health Super Fund The returns outlined below are the net returns declared by Health Super Pty Ltd as Trustee of the Health Super Fund up to 30 June 2011 for each investment option. However, these returns may not be the returns received by Health Super members if they changed their investment option during the course of the financial year. Returns marked n/a are not available because these options were not in existence at the time. For Health and Community Services MAY 2012 HILTON ON THE PARK MELBOURNE The Australian Centre for Healthcare Governance (ACHG) aims to support further development of the governance and quality of health services delivered to Australians through the public sector. This ACHG conference will explore contemporary themes in facilitating strong, integrated governance systems in health services: primary health and community services in the context of current health reform; issues of board structure and evaluation; leadership; clinical governance; research; multiple accreditation standards; strategy; tools; and processes to support effective governance will be addressed. REGISTER ONLINE NOW AT Investment Options Long-Term Growth Medium-Term Growth Performance from 1 July June 2011 Standard SRI Compound average performance over 5 years ending 30 June 2011 Standard SRI Compound average performance over 10 years ending 30 June 2011 Standard n/a n/a SRI...like Rosie Balanced n/a n/a Short-Term Conservative n/a Stopover 4.67 n/a 4.90 n/a 4.98 n/a Important information: Investment returns cannot be guaranteed as investment markets can be volatile. As a consequence, returns can be positive or negative. Furthermore, past investment performance is not a reliable indicator for future performance. The investment returns of the investment options under the former Health Super fund may differ from the investment returns of the investment options under the Health Super division of First State Super. Issued by Health Super as a division of the First State Superannuation Scheme ABN of which FSS Trustee Corporation ABN AFSL is the Trustee. This content is of a general nature only and does not take into account your personal objectives, situation or needs. Before making a decision about a Health Super product or service, you should read the Health Super Product Disclosure Statement (PDS) which is available healthsuper.com.au or by calling Rating applied to Health Super Fund as at 30 June SuperRatings compares the performance of superannuation funds. For more information about its rating methodology visit superratings.com.au Chris Deakin is National Business Development Manager Health Super Division. Nurse, alfresco bruncher and member since healthsuper.com.au Health Super is a division of the First State Superannuation Scheme ABN of which FSS Trustee Corporation ABN AFSL is the Trustee