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Managing the performance of the health care system


Performance of the health care system was put on the national agenda in 2010 when the then Prime Minister Kevin Rudd outlined his vision for the National Health and Hospital Network (NHHN). One of the features of the NHHN was improved reporting and performance standards. The precursor to this were the objectives, outcomes, progress measures and outputs that were agreed by the Council of Australian governments (COAG) in 2008 as part of the National Healthcare Agreement (NHA). Although aspects of the NHHN were re-negotiated, the commitment to improved transparency and accountability remained.

The Performance and Accountability Framework agreed as part of the National Health Reform Agreement provides a framework to improve the health care system. In addition, the National Health Performance Authority (NHPA) and the Australian Commission on Safety and Quality in Health Care have been established, information about public (and some private) hospitals is available through the MyHosptials website, My Medicare Local provides information about primary care and the Council of Australian Governments (COAG) Reform Council (CRC) has produced three performance reports about the NHA.

There is no shortage of reporting about the performance of the Australian health care system. The question remains, however, whether the information collected is meaningful with clear linkages between performance measures and objectives or outcomes. A complex reporting framework can hinder meaningful reporting. This concern was first identified in the CRC’s Baseline Report Performance Report of the NHA (2008-09). A recent Heads of Treasury Review of the reporting framework of the National Agreements and National Partnerships recommended changes to improve the overall conceptual adequacy and data quality of the NHA performance framework.

In response, the CRC has proposed a new reporting framework for the NHA. This considerably revises the previous reporting requirements.

Current FrameworkProposed Framework
One overarching objective
Seven long-term objectives
11 outcomes
26 progress measures
15 outputs
70 performance indicators
7 performance benchmarks
One objective
Seven outcomes
33 performance indicators
7 performance benchmarks

One of the challenges faced by the CRC was to balance the high level reporting requirements of National Agreements with monitoring of the performance of the health care system. The proposed reporting framework focuses on indicators where ‘governments have levers for change’ (such as implementing policy settings to reduce the burden of chronic disease). Another objective of the proposed framework is to measure performance of the health care system as it responds to change (for example, the changes to financing of hospitals that were agreed in the National Health Reform Agreement).

As part of the streamlined approach to reporting, where possible, data is disaggregated according to indigenous status, disability, remoteness and socioeconomic status. This will help provide a more comprehensive picture of the performance of the health care system as whole. The CRC acknowledges that further refinement of the framework and data input is required and expects that this will be available from 2014, after the release of the results of the National Health Measures Survey component of the Australian Health Survey. It has recommended further work on the development of a performance indicator to measure the sustainability of the health care system (notwithstanding the conceptual difficulties associated with such a measure).

As the Chairman of the CRC has noted, the CRC are the ‘building inspectors, not the architects’. This highlights the challenge associated with performance reporting: how can this information be used to improve the performance of the health care system? Secondly, how can the local reporting by the NHPA (and others) be reconciled with the high level reporting of the CRC? One of the central tenets of improving the performance of the health care system is access to the best available information by clinicians and patients but how do governments, clinicians, policy makers and patients make sense of these multiple reports? Improvements to the health care system are usually the result of ‘distilled learnings’ from multiple research projects over long periods of time.

In an analysis of US states with high performing health care systems, the Commonwealth Fund has identified the necessary pre-requisites:
  • Long history of government leadership on health care reform
  • A culture of collaboration among stakeholders (internal and external to government, including NGOs)
  • Transparency of price and quality information
  • A congruent set of policies that focus on system improvement

Linkages across government portfolios to deal with policy challenges outside of the health care system (such as obesity) and an understanding of the social determinants of the health was also considered fundamental to improving the overall performance of the health care system.

The structure of the Australian health care system poses many challenges to the attainment of these pre-requisites. And the spirit of collaborative federalism has been strained in recent times. There is potential for the health reform package to deliver improvements to the health care system but implementation is in the early stages. An improved reporting framework will ensure that governments are ‘accountable for achieving the objectives to which they have agreed’.