Australian states and territories have a long history of independent reviews leading, cyclically, to the centralisation and decentralisation of management and governance at various times. In 2004–05, Australian jurisdictions are, in the main, in a centralisation phase. Queensland is the subject of an independent review at the time of writing while Western Australia has a Health Reform Implementation Taskforce in progress. Dwyer [7
] reviewed the round of reviews in the Australian health system between 2002 and 2004. These resulted in restructuring in New South Wales, South Australia, the Northern Territory, Western Australia, and the ACT. There is a strong tendency towards increasing centralisation so that, in 2005, 6 of 8 jurisdictions now directly manage public sector health services, with Victoria and South Australia having mixed models. With the recent centralisation of management in New South Wales, Dwyer calculated that two thirds of Australians now live in areas under centralised control [7
Given this, the structure and effectiveness of jurisdictional health authorities is becoming increasingly important in determining whether reforms are achieved in areas such as clinical governance, quality and safety and others included in the National Reform Agenda. This is especially the case given that, at the same time, the centralised authorities will continue to devote considerable resources to responding to each new 'crisis' in their service system.
Table summarises the management structures in place in each jurisdiction in May 2005. As this summary indicates, there are significant differences in the role and scope of the various health authorities. This has important implications in relation to structural opportunities to reform and improve the coordination and planning of service delivery, particularly for those with complex and continuing care needs. At the same time, there is little similarity in how the various departments are organised, as reflected in their executive level divisional structures (listed in alphabetical order in the table).
Management of health and human services by jurisdiction – the state of play in 2004–2005
At a national level, the department is responsible for both health and ageing. But the health care needs of war veterans are the responsibility of the Department of Veterans Affairs (DVA) and not the Department of Health and Ageing (DHA). The 'ageing and aged care' functions of DHA include community care programs and services such as the Home and Community Care (HACC) program that are managed by the health authority in all but two jurisdictions. New South Wales has a separate Department of Ageing, Disability and Home Care. In South Australia, the previous Department of Human Services was split on 1 July 2004 into two, with a new Department of Families and Communities taking responsibility for, among other portfolios, community care and disability.
In 2005, an authority with broader human and community services responsibilities is managing health care in the Northern Territory, Tasmania and Victoria. These other responsibilities include, among some others, disability services and housing. Neither function is now within scope of the health departments in the other jurisdictions.
Tasmania has the broadest role and is responsible for both the policy and direct operations of its ambulance service. This is not the case in either Victoria or the Northern Territory where the department manages policy but ambulance services are separately incorporated. In other states with a narrower 'health department', ambulance services are managed by departments of emergency services (ACT, Queensland), by the health department (New South Wales) or are separately incorporated services (South Australia).
All jurisdictions now have independent authorities (however named) to review health care complaints. The ACT and South Australia established theirs in 2004. However, important differences in the philosophy and role of such bodies were identified in evidence given to the Special Commission of Inquiry into Campbelltown and Camden Hospitals [20
], particularly in relation to their role in 'blaming' those responsible for errors.
Western Australia and New South Wales have gone further. An independent Office for Safety and Quality in Health Care was established in Western Australia in 2002. It is responsible for supporting the establishment of effective quality and safety systems, as well as investigating complaints. New South Wales established a separate Clinical Excellence Commission in 2005 (replacing its previous Institute of Clinical Excellence). Not surprisingly, both initiatives followed major media coverage of 'hospital scandals' in those two states.
Organisational and executive structures differ between jurisdictions. As one example, public (or population) health is its own division, and reports directly to the departmental head, in the ACT, WA and NSW. In Victoria, it is an office within the Rural and Regional Health and Aged Care Services Division while in Queensland it is a branch within the Health Services Division. Population health functions in the Northern Territory also sit in a Health Services Division, but not in one branch. Instead, population health is the responsibility of several sections including the Centre for Disease Control and a Health Development and Oral Health Branch. In Tasmania, population health is a subdivision of the Community, Population and Rural Health Division. At least in part, these differences reflect the scope of the various departments. However, there is no evidence to suggest whether any of these structures produce more effective policy than others. Nor is there evidence on what structure is best able to manage the health system and its reform.
As one further example, workforce reform (one of the five 2004 AHA policies and also on the Australian Health Ministers Health Reform Agenda) is managed differently across the jurisdictions. In 2005, Queensland has a new Innovation and Workforce Reform Directorate while Western Australia announced in May 2005 the creation of a new Clinical Reform and Policy Division. In other jurisdictions, there is either no organisational unit responsible for workforce reform or it is incorporated in the functions of other sections such as human resource departments. As before, there is no evidence to suggest whether any of these structures will be more effective than others in delivering on the workforce reform agenda.
One reason for the differences between jurisdictions appears to be the circumstances that triggered each of their latest restructures. As Dwyer [7
] notes, all but one (NSW) arose from an independent review with the reorganisation of NSW coming in the aftermath of a hospital 'scandal' that attracted much media coverage. On the same basis, a number of reviews are now underway in Queensland.
In response to the so-called 'Doctor Death' scandal in relation to the appointment of Dr Jayant Patel in Bundaberg (Queensland), the Queensland Premier (not the Health Minister) announced in April 2005 the Queensland Health Systems Review. Its establishment had been the suggestion of the major doctors lobby group, the Australian Medical Association (AMA) [21
]. This major review of Queensland Health's administration, management and performance systems is due for public release on 30 September 2005.
At the same time, three other inquiries have been commissioned. A Commission of Inquiry has been established to investigate events at Bundaberg Hospital, including the role and conduct of the Queensland Medical Board in relation to overseas trained medical practitioners. Like the Queensland Health Systems Review, it has also been asked to consider changes to recruitment, employment and supervision of medical practitioners, management of complaints and measures to increase the availability of medical practitioners across the State. In parallel, the Crime and Misconduct Commission is also conducting a public inquiry into Queensland Health's handling of complaints regarding care at Bundaberg Hospital and a Queensland Health review of clinical services at Bundaberg Hospital is also underway [22
The Queensland Health Systems Review has broad terms. The administrative systems to be examine include (among other matters) district and corporate organisational structures and layers of decision making; corporate planning and budgeting systems; the effectiveness of performance reporting and monitoring systems; quality and safety systems; and clinical audit and governance systems. On the workforce front, it will examine recruitment; retention; training and clinical leadership. It will also review performance management systems including asset management and planning, information management and monitoring systems.
Regardless of the detail, it seems unlikely that the status quo will remain in Queensland in 2006. No doubt other jurisdictions will be watching in an attempt to learn the lessons.