I well remember that, after the last war, my medical colleagues returned to Australia filled with a desire to apply to the civil community the great lessons of successful medical control and prevention of disease which had been applied in the army. I remember, too, the progressive sense of depression and disillusion with which they came to realize that there was no place for such measures in the civil social system.Dr J.H.L.Cumpston, Commonwealth Director-General of Health, 1921–45.
Introduction/Background:
Palliative care patients and their family carers have complex needs and must access a range of support services to manage at home and maintain their quality of life. Paying for these services can impose a financial burden on households that may have already fallen into economic hardship due to long term chronic illness, sudden loss of income or the general stresses of low fixed incomes and high living expenses. This paper describes the use of health and community services by patients enrolled in specialist palliative care at the Calvary Health Care Bethlehem service in Melbourne, Victoria. their associated out-of-pocket spending and its impact on their economic circumstances at the end of life.
Methodology:
A mixed-method prospective design. Patients enrolled in specialist palliative care (n=30) and their nominated carers (n=22) participated in semi-structured interviews regularly over a six month period. Each patient also completed a care diary recording health and community service use and out-of-pocket spending over a 2 week period.
Findings:
Sixty percent of participants reported experiencing economic hardship and this was felt most severely by those recently out of the workforce due to illness and individuals who didn’t own their home. Most commonly people reported difficulty paying for medical expenses, including medical tests and medications and used their limited savings and borrowed money to maintain their living expenses. In a two-week period, patients attended on average two health care appointments and used two community services and spent a median of AUD$88 on medical and supportive care expenses. The majority of participants felt they were struggling financially and faced difficulty accessing the social welfare supports currently in place.
Policy Implications:
This research provides a basis to explore the additional policy supports required to assist patients and their families to better cope with the economic pressures at the end of life.
The conflicts of the 1940s and 1950s left Australia with a particularly rigid set of institutions. Despite claims by the federal government and organized medicine that the Page scheme was a victory for free enterprise, it had required a major expansion of state intervention in the market for medical services. Fee-for-service was enshrined as the central principle of medical remuneration, but only at the expense of handsome subsidization by the taxpayer. Pensioners were now guaranteed free personal health care, but specialist services continued to be excluded. Rigid means testing limited access even further – with a more rigorous income test which removed health benefits from many old age pensioners. At the same time the constitutional and political limits to direct control of price levels and planning of medical and hospital services set extraordinary barriers to the management of public expenditures. Hospitals remained the province of the states, with vast differences in financial arrangements, equity of access and regulation. The ambitious schemes for co-ordination of general practitioner, public health and institutional services had come to nothing.
Abstract Background Chronic illness is a significant driver of the global burden of disease and associated health care costs. People living with severe chronic illness are heavy users of acute hospital services; better coordination of their care could potentially improve health outcomes while reducing hospital use. The Care Navigation trial will evaluate an in-hospital coordinated care intervention on health service use and quality of life in chronically ill patients. Methods/Design A randomised controlled trial in 500 chronically ill patients presenting to the emergency department of a hospital in Western Sydney, Australia. Participants have three or more hospital admissions within a previous 12 month period and either aged ≥70 years; or aged ≥45 years and of Aboriginal or Torres Strait Islander descent; or aged ≥ 16 with a diagnosis of a respiratory or cardiology related illness. Patients are randomised to either the coordinated care program (Care Navigation), or to usual care. The Care Navigation program consists of dedicated nurses who conduct patient risk assessments, oversee patient nursing while in hospital, and guide development of a care plan for the management of chronic illness after being discharged from hospital. These nurses also book community appointments and liaise with general practitioners. The main outcome variables are the number of emergency department re-presentations and hospital readmissions, and quality of life during a 24 month follow-up. Secondary outcomes are length of hospital stay, mortality, time to first hospital re-admission, time to first emergency department re-presentation, patient satisfaction, adherence to prescribed medications, amount and type of in-hospital referrals made for consultations and diagnostic testing, and the number and type of community health referrals. A process evaluation and economic analysis will be conducted alongside the randomised trial. Discussion A trial of in-hospital care coordination may support recent evidence that engaging primary health services in care plans linked to multidisciplinary team support improves patient outcomes and reduces costs to the health system. This will inform local, national and international health policy. Trial registration Australia New Zealand Clinical Trials Registry ACTRN12609000554268
In this conceptual piece, we take a narrative approach to explicating the gap between organizational theory and practice. The narrative pentad ( what, why, how, who, and when/ where) represents six narrative questions metaphorically mapped to the five fingers of the hand. The narrative pentad has successfully served both narrative scholars and practitioners, and we believe that the narrative pentad holds similar promise as a theoretical framework for HRD scholars and practitioners. At the finger tips, spaces between fingers represent gaps between questions. In the organizational domain, the theory–practice gap is attributable primarily to a scholarly focus on the universal and abstract what and why questions (story in narrative terms) and a practitioner focus on the particular or embodied how question (discourse in narrative terms). Framed as similarities, we propose that all HRD questions are interrelated at the palm of the hand. In narrative terms, effective organizational theory must include both story and discourse, thereby addressing all questions. This article emphasizes the how question—important to practitioners—but often marginalized by postpositive organizational scholars. We propose the how question represents aesthetic knowledge, and this form of knowledge should be central to organizational theory. We explore related ontological and epistemological considerations. Three recognized causes of the theory–practice gap are examined in light of a narrative approach to organizational theory: (a) the knowledge divide (divergence of emphasis on forms of knowledge between scholars and practitioners); (b) the knowledge transfer problem (lack of information sharing between scholars and practitioners); (c) and the knowledge production problem (associated with an absence of collaboration between scholars and practitioners).
Public health researchers make a limited but important contribution to policy development. Some engage with policy directly through committees, advisory boards, advocacy coalitions, ministerial briefings, intervention design consultation, and research partnerships with government, as well as by championing research-informed policy in the media. Nevertheless, the research utilization literature has paid little attention to these diverse roles and the ways that policymakers use them. This article describes how policymakers use researchers in policymaking and examines how these activities relate to models of research utilization. It also explores the extent to which policymakers' accounts of using researchers concur with the experiences of "policy-engaged" public health researchers.We conducted semi-structured interviews with thirty-two Australian civil servants, parliamentary ministers, and ministerial advisers identified as "research-engaged" by public health researchers. We used structured and inductive coding to generate categories that we then compared with some of the major research utilization models.Policymakers were sophisticated and multifaceted users of researchers for purposes that we describe as Galvanizing Ideas, Clarification and Advice, Persuasion, and Defense. These categories overlapped but did not wholly fit with research utilization models. Despite the negative connotation, "being used" was reported as reciprocal and uncompromising, although researchers and policymakers were likely to categorize these uses differently. Policymakers countered views expressed by some researchers. That is, they sought robust dialogue and creative thinking rather than compliance, and they valued expert opinion when research was insufficient for decision making. The technical/political character of policy development shaped the ways in which researchers were used.Elucidating the diverse roles that public health researchers play in policymaking, and the multiple ways that policymakers use these roles, provides researchers and policymakers with a framework for negotiating and reflecting on activities that may advance the public health goals shared by both.
Man has an individual and a collective fear: his fear of sickness and helplessness is for himself and those whom he loves. This applies to all, but presses especially heavily on the man with a small income. He is afraid that sickness will come upon him or his family and that he will not be able to earn if he is ill, or cannot meet the hospital and medical expenses for his wife or children: the fear of want and fear itself are one. This fear lives with him as a daily companion until the moment comes when he, like Job, must cry, 'The thing which I greatly feared is come upon me'.It is to some degree possible, by thrift, to lay by a small reserve against temporary periods of economic stress, but provision for the crippling debts of illness has not hitherto been possible.The [Commonwealth Government's] scheme … is designed to remove this fear.Senator James M. Fraser, Minister for Health and Social Services, 1944
No area of social welfare in Australia has seen as much conflict as health policy. Clashes have involved the medical profession, bureaucrats, friendly societies and political parties, often to the detriment of the patient. This 1991 book provides background to the current debate by studying the political conflict over health policy in Australia from 1910–60. It looks at both state and national levels for the origins of the system of publicly subsidized private practice epitomized in the fee-for-service scheme. The different currents within state policy are analysed along with the various obstructions to the development of the national health insurance policy. The role of the British Medical Association, which in its indigenous form continues to have a hostile relationship with the government because of its determination to maintain its independence and fee-for-service practices, is closely examined. The Price of Health will be of particular interest to health policy makers.
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