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Fit for the futurePlanning for the Future: NSW Health 2025

A Submission by the Disability Council of NSW

to the Inquiry of NSW Health on the future directions for health in NSW

Key comments made in this submission

NSW Health is to be congratulated on initiating consultation to establish consumer views on the future of health services.

Equitable access to health care is central to developing an affordable, high quality system, which is capable of sustaining a healthy community. That equity will not be achieved for people with disability until structural and attitudinal barriers are eliminated.

Advisory bodies to NSW Health need to include people with disability who are more often aware of the existing structural barriers which work against equitable service delivery.

Strengthening primary health and continuing care in the community must be fundamental to the future success of our health system.

Targeted health promotion for people with disability, including funded preventative health care for designated groups with poorer health outcomes, is essential to the well-being of people with disability. Targeted health promotion has the incidental benefit of reducing costs elsewhere in the health system and/or later in the life-cycle of individuals with disability.

The current silo mentality of Area Health Services (AHS) must be addressed further to reduce costs and improve the experience of people with disability accessing the health system.

A person-centred approach is needed across the whole health service system. Service system responses to people with disability presenting for treatment (or support) should be no less individualised than responses to those without disability. This is not always true in today’s service system.

Redesign of the workforce is essential over the next 20 years. We should not maintain the traditional hierarchy of 19th and 20th Century health service models, often based on acute services. We need a 21st century workforce with modern skill sets and contemporary relationships.

The development of alternative models of care will improve experience of the health system, reduce costs, and ensure people are better able to function effectively in the community.

The practice of addressing smoking, excessive alcohol consumption, obesity and other health risks needs to be supported with a greater percentage of the health budget. Prevention is better than cure and early-intervention should be the default value of health promotion strategies.

Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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A seamless service system is required across Government. Its development cannot be limited to improvements in one department (e.g. NSW Health). Both primary health care and prevention should be everyone’s business. A Whole of Government approach and interdepartmental co-operation is essential to its success

About the Disability Council of NSW

The Disability Council of NSW was established by the Community Welfare Act (1987) to advise Government in NSW on issues affecting people with disability and their families. We also give advice to the Commonwealth Government on the effect of policy on people with disability living in NSW.

Council members are appointed by the NSW Governor. They are selected on the basis of their experience of disability and their understanding of issues, their knowledge of service delivery and their ability to reflect and advise on government policy. The majority of Council members are people with disability.

Terminology used in this submission

The Disability Council of NSW is referred to as Council and the NSW Health Department as NSW Health throughout the submission. Acronyms for all other bodies referred to in the submission are noted when first referenced.

Structure of the Submission

We have chosen not to respond directly to the questions asked in the Fit for the future questionnaire. We were not persuaded that its structure would allow us to comment in ways that we believe add value to the discussion. Council has, therefore, stepped beyond the confines of the questionnaire to discuss issues of the current health system and its future needs as they affect people with disability.

It is important that we note our fundamental view: The Disability Council of NSW endorses the seven strategic directions identified by NSW Health as needing to be addressed in developing a more responsive health system for the future. Following our more general comment on disability and the role of the health care system, we consider each area in turn, outlining connections with the lives of people with disability.

Defining Disability

The term ‘people with disability’ is used throughout the submission. We hold to the view that disability is not an individual trait or condition. Our advice is premised on a social model of disability, such that the source of disability is not impairment, but socially and economically constructed discrimination and exclusion.


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While not disregarding the experience of impairment and illness in the lives of some people with disability, our primary goal is contribution to the realisation of a socially just community in which Government policy and practice reflect the lives and experiences of people with disability – acknowledging their rights as citizens, respecting their choices, and valuing their contributions. Those rights include the right to health.

Incidence of disability

In 2003 the Australian Bureau of Statistics (ABS) reported that one in five people in Australia (3,958,300 or 20%) had a reported disability. 1.

A further 4,149,000 (21%) had a long-term health condition that did not restrict their everyday activities.

In the same publication ABS noted that in 2003, there were 3.35 million people aged 60 years (17% of the population). Just over half of that number (51%) had a reported disability. With the ageing of Australia’s population it is anticipated by 2025 that a much higher percentage of the population will identify as having a long term health condition or as a person with disability.

PERSONS WITH A DISABILITY: IMPAIRMENT TYPES

In an earlier publication (1998) the ABS released statistics on disability and long tem health conditions which demonstrated that over half of all people with disability have a physical impairment, either alone (30%) or in combination with another impairment (27%). More than one-third (37%) had a sensory impairment, around half of these (18%) having a sensory impairment

1 4430.0 Disability, Ageing and Carers – Summary of Findings, ABS 2003.Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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only. Other types of impairment are less common, 18% with psychological and 9% with intellectual impairment.2

Increases in our population of people ageing with disability and the significant numbers of the population of all ages with disability will increase pressure and demand on the health care system. Almost all stakeholders agree that in its current form the health system will not be able to address the needs of the population changes we can foresee in the decades to come.

Widening the focus: the changing meaning of health care

Forty years ago the distinction between health care and medical care was difficult to define. Whether through hospitals or General Practitioners the onus of health care was to treat the sick.

Over the last 40 years, however, the lens has been widened. People see the health system as a system of maintaining a healthy lifestyle, addressing health, as opposed to the hospital system which is to cater to the sick. An illustration of this change of focus is to be seen in the change in direction of health insurance. The future direction of the health care system must take this shift into account as the society has redefined the health care system to one responsible not only to prevent illness but to promote well-being.

The challenges of the health care system

It is Council’s view that a principle aim of Government should be to ensure the social, attitudinal, architectural, medical, political and economic environment is sufficient to address the differences of all individuals. Accordingly, equitable access to the health care system is seen by Council as part of the fundamental set of rights of all citizens, including people with disability.

Currently, as we demonstrate below, attitudinal and structural barriers effectively block equitable access for people with disability. Addressing these shortcomings must be central to any attempt to ensure an affordable, high quality system sustaining a healthy community in 2025.

In his press release on Fit for the future the NSW Premier identified 6 main challenges facing the current health care system, these being:

the growth and ageing of the population; the consequence of increased life expectancy; the increased risk of chronic illness due to changing lifestyles; the need for preventative strategies; health workforce shortages, and ongoing medical advances and new technology leading to raised

expectations.

We concur with the Premier’s observation. We would also add these challenges:

current and continuing inequities of access to the health care system;2 4433.0 Disability and long term Health Conditions, ABS, 1998.Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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poorer health outcomes of specific population groups, eg, people with disability, the Aboriginal population, people from non-English speaking backgrounds;

the need to meet the ongoing health needs of people surviving accidents / injuries beyond their acute medical care and rehabilitation (where previously death might have been a more likely outcome in some circumstances);

technological, medical and/or drug therapy advances that may combine to secure life, where previously death may have been more likely, but which may result in more people with disability with sometimes high levels of need for medical or health-related intervention and/or support.

the need to consider the accessibility and affordability of preventative healthcare for specific target groups, eg, dental care and dieticians for people with intellectual disability or aphasia;

the challenges of a multicultural communities, eg. health awareness and information provision in community languages;

increased awareness of and client commitment to alternative or complimentary therapies and health practices drawing on traditions other than the dominant, Anglo-Saxon culture of Australian health care.

private health insurance expansion to cover in home health costs to minimise the need for high cost hospital care;

These challenges require prioritising the goals for the future health care system.

Council lists our priorities below.

Good health care outcomes for all, including people with disability.

Equity – with additional resource commitments made to assist people with persistently poorer health.

Community participation - communities participating in the decision-making process.

Consumer-focus – where services respect individual dignity, culture and preference.

Individual participation - consumers and their families participating in decision-making about their care and treatment.

Safety and quality – services are safe for consumers and providers, and are of assured quality.

Cost – services are affordable for consumers. Timeliness – consumers can access services without avoidable delay. Proximity - basic health services are available close to where we live. Expertise – there are sufficient numbers of appropriately skilled staff. Preventive focus – there is an emphasis on helping people stay

healthy for as long as possible. Early intervention Synergy – a whole of government approach ensures services are co-

ordinated to smooth each consumer’s journey through the health system (including post release care).

Evidence-based – services are based on research findings about what works best.


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Physical environment – services are provided in accessible, clean, friendly and comfortable settings.

Information – accessible to all, including those with vision or hearing impairments, people with intellectual disability and people whose first language is not English

Efficient and accountable management – resources are used well decisions are explained.

Interface with health care: the experience of people with disability

We are happy to acknowledge that health care systems and services can and do work well for people with disability but there are highs and lows in the quality available. There is a lack of consistency across the State. The challenge faced by all stakeholders is to turn the best practice of inclusive service provision into the standard practice for the whole service system.

People with disability encounter, disproportionately, significant negative challenges within the health care system arising from structural, organisational, and attitudinal barriers.

There are two fundamental obstacles to overcome. Each limits equitable access to health services, restricting the opportunities of people with disability within the service system and working against the maintenance of good health. Both sets of obstacles are preventable. They are:

The design of the built environment of health services .

From the design and construction of local medical centres, General Practice consulting rooms, hospital facilities to the provision of basic equipment (examination tables that are not height adjustable) the physical environment creates barriers for people with disability. This is not simply matter of concern for people who use wheelchairs (although they are an important group with common and frequent access problems to overcome). If the ABS is correct that almost two-thirds of people with disability have a physical disability that in some way limits the ability to function on a daily basis , the need for the physical world of modern health services to be inclusive is clear.

The need for equitable access to facilities for people with mobility disability is a civil rights issue that the health system must address.

Many practitioners deliver services in inaccessible premises. Education of practitioners, or a requirement placed on them to operate from accessible premises, are two means of addressing the issue.

In a survey of examination couches conducted in 2003 it was found that in NSW 3,518 fixed height examination beds were identified, across 917 surgeries compared to only 125 adjustable height examination beds3.

3 http://www.humanrights.gov.au/disability_rights/health/access.docDisability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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This is clearly a matter to be addressed by NSW Health or the Minister for Health.

Access to information about and within health services

Many people have difficulty accessing or understanding information because of the ways in which it is produced or made available. Information is often provided in forms that are inaccessible to people with vision impairment (not only blind people). Plain English information is often not available so that it could be understood by more health service clients, including many people with intellectual disability. And, with as many as twenty-five per cent of the population of people with disability coming from a non-English speaking background, a requirement for all information to be made available in community languages at the point of need is clear .

Beyond these fundamental pillars of equitable service provision – accessible environments and accessible information – we draw attention to key aspects of the interface with health care which can be problematic for people with disability unless clear consideration is given to developing inclusive processes.

Flexible service delivery

We recommend a review of procedures to allow greater flexibility avoiding unnecessary and costly visits to practitioners.

One illustration suggesting the need for a more flexible system is the situation of people on long term medication. Scripts normally carry ‘repeats’ for people who use a drug as treatment for an ongoing condition (e.g. Lamotrigine, used to treat epilepsy and/or bipolar disorder). The condition, once stable as a result of the drug regime, is likely to remain so. Yet, at present, repeat visits to practitioners are needed to have further scripts issued. The matter might be addressed by linking the recipient with a local chemist given authority to supply the drug for a twelve month period. .

Easing the patient journey through the health service maze

The current heath system, particularly the hospital component, is complex and at times confusing. We must establish simpler, more effective and less intimidating ways to support people during their engagement with health services and providers.

Council suggests the establishment of a position similar to that of the ‘patient’s friend’ adopted in Britain to assist with in hospital process issues would assist in reducing this complexity. Making information available in alternative formats will also aid the process.


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Multi-disciplinary approaches

We favour multi disciplinary approaches / holistic practice wherever practical. This can be essential when people have complex needs (e.g. people with aphasia). While any health care team will need a leader or co-ordinator of services, there are demonstrable benefits from practitioners breaking down professional boundaries to work together in the interests of health care clients. We stress, however, that multi-disciplinary practice must be person-centred, driven by the wishes / needs of the recipient of the service.

Eradicating service silos

Current restrictions on flexibility within and between Area Health Services (AHS) and between Health and other service providers must be broken down to reduce costs and improve the experience of people with disability accessing the health system. One example of silo mentality resulting in poor practice demonstrates our point.

Council has been made aware of the case of a service user in rural New South Wales who, following injury, needed home modifications before being discharged from a rehab unit. An Occupational Therapist (OT) was needed to assess the means of best meeting the client’s ‘home mods’ needs. The OT service closest to the client’s home and immediately available was a non Government provider. The AHS would not pay for an NGO assessment but, because of the distances and workloads involved, had none of its own OT assessors available within a reasonable timeframe. The client remained in a high cost hospital unit until a departmental OT was available to complete the assessment. The silo mentality cost the health service extra money and time. The costs to the client’s health, well-being, delayed re-integration, family disruption, were at least as severe.

Stereotypical responses

People with disability experience attitudinal barriers when dealing with the health care system. In current circumstances people with disability are often treated as if all presenting symptoms are necessarily related to a person’s disability. This is not always the case.

For instance, a blind person presenting with an ear infection may be forced into paying for a long consultation because practitioners concentrate their inquiries on the issue of blindness. Alternatively, as part of normal practice, if a person with a psychiatric disability presents at an emergency department with significant heart pain a psychiatric nurse may be called (often before the heart pain is investigated). Similarly, people who have been diagnosed as having a psychiatric disability or mental illness may have their anger ‘pathologised’ and their complaint ignored should circumstances arise which lead them to express anger or frustration over dissatisfaction with their engagement with a health service or provider.


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The onus of practitioners and standard practice in hospital to address the impairment rather than concentrating on the presenting condition, like the questions asked by ill informed ‘professionals’, suggests a clear need for training to improve knowledge, skills and address stereotypes.

Working with and for individuals

Each health service user is unique. They should be respected as individuals, deserving the dignity and attention to personal detail that any of us might wish for.

The training of health professionals creates a tendency towards thinking that sees all patents as more or less the same. There is a standard set of questions or common set of assumptions that underpin the communication skill set of many practitioners. This can have particularly troubling consequences for people with disability.

For example, we know of people with pre-existing paraplegia or quadriplegia who have injured a leg and have been asked by a locum applying pressure to the calf muscle: “Can you feel this?” Similarly radiologists, when taking X-rays, request they keep their legs still. Such approaches to increasing understanding or making diagnosis are ineffective, failing to take into account the unique circumstance of particular situations. The professional must think more clearly and engage more imaginatively with each individual rather than any pre-conceived idea of how a patient is supposed to behave or respond.

A person centred approach is needed across the whole health service system. Assumptions made about the needs of people with disability presenting for treatment (or support) should be identical to those made about others.

Strengthening primary health care

Council considers strengthening of primary health and continuing care within the community to be fundamental to the future success of our health system.

When introducing the Report of the NSW Health Council in 2000 the chairperson noted “about 12% of the population is admitted to hospital in any one year. Yet public hospitals absorb about 57% of the the total state Government Health expenditure.”4

We stress our view that although the majority of the health budget is directed into maintenance of the hospital system it is support outside hospital (in home support as well as preventative therapies) that will reduce costs and allow people with disability to function better as part of their chosen community.

4 John Menadue AO, Chairman’s Message, Report of the NSW Health Council: A Better Health System for NSW 03/2000, NSW Government, March 2000Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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The methods of delivering primary health care need to change. At present, specialists and clinicians are often employed in roles that could legitimately be filled by people with no different qualifications or training. Essential support services for people with disability are currently the domain of qualified clinical rehabilitation specialists when such expertise is not necessarily essential. Where possible support services should be provided effectively by those without such skills or qualifications to save costs and reduce the medical focus of support.

A change to the role of case worker is recommended. While some exist in under-funded Crisis Teams for people with psychiatric disability they are rarely available to provide support until a mental health problem occurs that puts the individual at risk.

Caseworkers generally fill specific roles (e.g. rehabilitation) restricted to assistance with a particular difficulty in an individual’s life. They do not provide general or ongoing support though this may be needed. Expanding the role might require a change of name (e.g. to support worker). The role could then be applied to a wider range of areas of a person’s life impacting on their experience of the health system.

At present the support system or worker controls which services are offered as well as, ‘how’ and ‘when’. The needs of the person requiring support often become secondary to the decisions made by the employer regarding employee availability. This leads to frustration. For instance a person requiring assistance to get to and from bed may need to be in bed at dusk if the support team will not work at a later hour (when others would normally retire). A brokerage model should be established so that those requiring support can determine who provided their support.


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Future directions for the health system of NSW

We broadly endorse and support the seven future directions identified by NSW Health in “Fit for the future”. We comment briefly on each of the seven in the section that follows.

Making prevention everyone’s business

It is not uncommon for health prevention with regard to people with disability to be understood in narrow terms linked to ‘cures’, reducing the incidence or effects of injury or eradicating or ameliorating birth ‘defect’ Some of that narrow focus makes sense e.g. road safety campaigning to reduce the incidence of motor vehicle related spinal cord injury. At an extreme position, however, some of that focus may border on a eugenics approach, which devalues human beings because of the presence of a disabling condition (e.g. genetic screening with a view to embryo selection).

It is not credible to imagine that all disabling conditions can be prevented. The longer the delay in identifying or responding to the occurrence of a disabling condition, especially in children; the more costly and profound will be the whole of life consequences. Better diagnosis, response times and reporting back mechanisms are needed in early intervention centres when concern is first expressed (i.e. prior to definitive analysis/diagnosis being established). Thus prompt action may reduce cost and parental anxiety.

Preventative measures ought to improve both the functional capacity and the life experience of individuals. Post-injury, disease or birth, by which time a disabling condition has become a reality, preventative measures for promoting good health or avoiding ill-health are just as important to people with disability as they are to the rest of society. They are sometimes more important because they can reduce the effect of pre-existing conditions or impairment. For this reason it might be expected that people with disability would be primary targets of prevention strategies.

However attitudinal and structural barriers combine to limit access to prevention strategies for people with disability. For instance, the crisis in preventative health care of people with intellectual disability has been well documented over the last twenty years though it is still not seen as a health priority5. The findings speak for themselves.

The life expectancy of a person with an intellectual disability is approximately twenty years lower than the general population.

In Northern Sydney, 42% of medical conditions went undiagnosed in people with intellectual disabilities and half of the diagnosed conditions were inadequately managed

Obesity for people with intellectual disabilities is up to three times the level in the general population.

5 http://www.nswcid.org.au/systemic/position/health.htmlDisability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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42% of 211 people with disabilities who died in care were underweight and some died because of critical illnesses being untreated.

Dental disease was up to seven times more frequent among people with intellectual disability than in the general population.

Women with disability have argued that their health needs are often overlooked in preventative health campaigns and their specific needs ignored. The national non-government association called Women With Disability Australia has observed:

Some limited analysis can be gleaned from the Australian Longitudinal Study on Women’s Health (ALSWH). This study showed that, despite the fact that the risk of developing and dying from breast cancer increases with age and that the risk is highest for women aged over 70 years, 41% of women aged 70-75 with core activity restriction had never had a mammogram. Almost 30% of women in this cohort had never had a pap smear, 39% have not had regular pap smears

In 1999, the Commonwealth Office of Disability (Department of Family & Community Services) commenced analysis of the 70-75 cohort of the ALSWH survey to determine whether it could provide reliable data on which to base future policies, plans or programs for older women with disabilities. However, this analysis was abandoned by the Commonwealth Office of Disability in 2000, as it was not considered 'a priority'.

It is possible that women with disabilities face an increased risk of breast cancer for a variety of reasons, including: more frequent x-rays; differences in exercise and nutrition; prolonged use of certain medications, and late childbearing or nulliparity. Despite this, women with disabilities in Australia are not identified as an under-served population for the purposes of breast cancer screening, nor are they targeted by breast cancer organisations for education and outreach6.

A similar picture emerges when we consider screening for cervical cancer7.

Preventative measures are often out of financial reach for people with disability. Disability, Ageing and Carers: Summary of Findings, 1998 (cited above) found that 47% of people with disabilities were in the lowest two income groups, compared with 30% of people with no disability. Thus private health insurance cover, gym membership or specialist fees are too costly and often complemented by increased transport costs to access these services.

Nor can a person with disability always rely on the expertise of practitioners undertaking preventative measures. One example is that of the person who, due to their impairment, needs regular physiotherapy and/or a tailored gym 6 http://www.humanrights.gov.au/disability_rights/health/wwda.doc7 ibid.,Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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program. Sports physiotherapists, like gym instructors, are often unable to deliver appropriate services. On the other hand specialist services are rare and costly.

Targeted health promotion for people with disability, including funded preventative health care for designated groups with current poorer health outcomes, is an essential way to promote well-being, reduce costs and minimise trauma. The difficulty of affording specialist services to maintain good health (identified above) also needs to be addressed.

Campaigns to develop prevention strategies and to reduce the prevalence of smoking, excessive drinking, obesity, unsafe road use and other health risks needs to be supported with a greater proportion of available funds. Those campaigns must recognise and overcome the barriers to information created for people with disability about which we have written above.

Council believes that financing health promotion, prevention strategies and healthy living is not solely the responsibility of NSW Health. The whole of government, State and Commonwealth, is responsible. It is essential that such campaigns need to include people with disability in the target audience. Their exclusion from current initiatives is more in keeping with a social attitude that sees people with disability as ‘tragic’ or victims rather than as members of a wider community with the right to expect equal access to quality health care.

Building regional partnerships

A seamless service system is required, although it should not be the sole responsibility of one department (NSW Health). If primary health care and prevention need to be everyone’s business, interdepartmental co-operation is essential to its success (see Whole of Government approach below).

Access to good health services ought not to be a postal code lottery. Nor should the administration boundaries of AHS define where treatment will take place unless there is a coherent case that it is in the best interest of the patient to be directed to a specific facility.

At present, the place in which treatment occurs is often dependent on the location of the person at the point of need. This requires the person to fit the needs of the system. Council argues the reverse: the health care system should be responsive to the needs of the individual. The development of regional partnerships is one method of fostering a change in practice to ensure the primacy of the person seeking health care.

Area Health Advisory Councils (AHAC) can support the focus on developing regional partnerships. Community participants on AHAC are essential providers of community views. Council argues that people with disability must be encouraged to join AHAC teams so that advice provided reflects their views.


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Similarly, partnerships between NSW Health and the community would be strengthened by ensuring greater participation by community representatives on state wide advisory bodies to complement and supplement the involvement of health professionals.

Making smart cost/benefit choices

We acknowledge that NSW Health is presented with ethical dilemmas when making cost benefit choices. This may be due, in part, to the fact that benefits in one area are matched by additional costs on the health system in another.

For instance, the ability to enhance survival rates of premature babies, as a result of life-saving surgery or cutting edge paediatric support, may be considered a ‘miracle of modern medicine’ and a welcome development. The longer term consequences, however, may be to pose new challenges to our health system if the result may be, in some circumstances, survival of children who will need special care and attention during schooling and in adult life. This welcome success at one point in the matrix may result in increased costs to the health system in other places and at other times, sometimes long after the initial successful health outcome. The need arises for systemic change to address the attendant problems of disability presenting throughout that person’s life.

Similarly, people involved in motor vehicle accidents, who might once have died as a result of injury but now survive because of seat belt or safety helmet laws, may have ‘normal’ life expectancies but live with profound degrees of brain or spinal injury, and the associated disability with all its social and financial consequences.

Nevertheless, we believe that simple procedures could be put in place to ensure smart cost/benefit choices are made. In the example we cited earlier of a client awaiting a NSW Health OT assessment, a simple change of business rules would have allowed a ‘non-standard’ solution to be found (i.e. using an external assessor) thereby freeing-up a much needed and costly resource (a hospital bed) for a more appropriate client. Another simple solution would be to delegate greater discretionary budget powers to front line staff.

Equity of access to service should be a base criterion for any cost benefit analysis. This does not mean that expensive new technology available in the inner city should be duplicated in the rural areas of NSW. It means, however, that such technology should be equally accessible to all.

At present much of the health care system is preferential to those able to pay (or make co-payment) for services. The public health care system should be no slower to respond or of lesser quality than that provided to those with private health care.

Red tape and duplication cost money. NSW Health needs to ensure the individual’s journey through the health system is both seamless and cost Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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efficient. The need to provide or re-create a case history at each interaction with a health professional is both time consuming and a waste of tax payer’s money. This can be true in the case of people with disability when the reason for presenting has no connection to a pre-existing disabling condition (e.g. when a Deaf man presenting with a broken collar bone is questioned about his hearing loss).

Timeliness of service delivery is another essential element of making smart cost/benefit choices. If a child waits 2 years for a wheelchair provided through PADP it is highly likely that the equipment will no longer meet the child’s need. The initial assessment is wasted, the equipment may no longer ‘fit’, the re-assessment will require further costs, professionals’ time will have been wasted and the delay in providing the right intervention in a timely manner may result in additional, avoidable health costs later in the client’s life.

NSW Health also needs to accept full financial responsibility for providing support when needed to address health needs of people with disability. For instance, in the case of people with aphasia, health care clinics providing ventilators for ventilator dependent people with quadriplegia should be funded wholly from the health budget rather than Department of Ageing Disability and Home Care (DADHC). The health care of people with disability is not the responsibility of DADHC but like all other members of the community people with disability should expect health care funded by NSW Health.

Redesigning, reinvigorating the workforce

Redesigning the workforce to meet the health care needs of NSW in the 21st Century is essential. We simply cannot afford to maintain the traditional hierarchies of consultants, surgeons, specialist clinicians, nursing staff, paramedics and ancillary health professionals. The development of nurse practitioners may be one critical means of addressing old problems.

All stakeholders must acknowledge that this will have consequences for the organisational culture and relationships of our multi-faceted health system. Past attempts at shifting workforce patterns, at all levels, have resulted in vehement political backlash from those who feel undervalued and/or that their professional validity has been challenged.

Our health services need a contemporary workforce with the skills sets and experience required to face new challenges. We must promote and develop cultural competency within the workforce, drawing upon the rich diversity of the State’s population. Practitioners need to be drawn from a broader range of our population (e.g. more female senior doctors, a greater proportion of nurses who are male, a more diverse set of upbringings for General Practitioners, Surgeons and others, etc).

Furthermore, training in cultural competence is recommended, not just because we need a diverse workforce, but as a necessary response to the fact of our multicultural society. Different cultures treat disability differently and have different views on the effectiveness of certain remedies. An Disability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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awareness of such issues will enhance practitioner client relations. In certain cases it may also allow the practitioner to suggest a means to improve the life of a family member with disability when the family may be unaware of resources available to provide support.

The training needs of practitioners need to be reviewed, revised and expanded if they are to properly address the needs of people with disability. Key matters of interest include developing the ability of all health professionals to listen better to clients; overcoming stereotypes of people with disability; focusing on person-centredness within holistic assessment and service delivery arrangements in health care settings and services. We need to shift the between practitioner and client to give more power and credence to the latter while respecting the training and expertise of the former.

Being ready for opportunity/risk

We agree that a contemporary health service should be ready to take / create opportunities and to anticipate / prepare for risks. No one would seriously argue, for example, that health planners in 2006 ought not to be considering how we might respond to a human pandemic originating from the current bird flu concerns. Similarly it would be foolish for prevention strategies not to be addressing now the emerging trends towards a more obese population.

Engagement with end-users – the patient or client base – is a fundamental necessity of being ready for whatever comes next or creating the next big thing. Our health services must continue to move from being driven by clinicians and professionals to being responsive to service users. Patient focused health care ought not to be regarded as a novel idea but as the norm of service delivery. Many people would be surprised to learn that person-centredness is not yet the default value of our health care system. After all, if a health service is not primarily about the people who make use of it, what purpose is it intended to serve?

The development of alternative models of care (in home support, drop in care) provides an opportunity to improve the experience of the health system, reduce costs, and ensure people are better able to function effectively in the community.

Cultural competence is required across the health system from practitioners to administrative staff. By ‘cultural competence’ we mean that the service provider is able to respond effectively to anyone who is eligible for the service, regardless of their cultural, linguistic, religious or social background. This would require a much more flexible approach acknowledging that how health is defined and treated appropriately varies with culture. Flexibility is required to support alternative medical practice; acupuncture, herbal remedies, etc if medical practice is to address cultural need/belief.


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A Whole of Government Approach

The building of a healthy community must become a Whole of Government responsibility. As such, Council argues that departments and Ministers should maintain an awareness of Government initiatives impacting on their core business though not initiated by them and provide comment where appropriate. Accordingly, NSW Health should connect with issues with the potential to impact on community health.

Some Government initiatives external to NSW Health have taken up the challenge. For instance Department of Housing (DOH) is in the processing of developing an Accord with Government agencies and NGOs providing services to DOH clients with disability (including those awaiting housing). Further, DOH has established an Ageing in Place Project. It has contracted Mercy Arms (an NGO) to take over a floor of a 31 storey tower (the Mattabai Building, Redfern) housing older clients and those with disability. The intent is that preventative and primary care is provided on site to allow ageing in place and continued community participation.

Stronger together : A new direction for disability services in NSW, a ten year plan for disability services is a document likely to have significance to the future delivery of health services in NSW, as they affect people with disability. It is Council’s view that NSW Health should develop Memorandums of Understanding with different departments (e.g. DADHC) or initiatives similar to the DOH Accord to ensure appropriate primary care to people with disability. A clear example needing clarification of responsibility is the support of people with psychiatric disability where it is the responsibility of DADHC to provide support to people to function effectively in the community and the responsibility of NSW Health to address issues, in the community as well as hospital, of those presenting with mental health problems.

In much the same way, health policy needs to connect with and inform other government policy. The housing component of the State’s metropolitan strategy is a good illustration of what we mean. Most accidents occur in the home. The metropolitan strategy proposes the construction of 170,000 new homes in the western, southern and northern regions of the conurbation. Will these new communities be served by inclusive health services?.

Drilling down further into the detail of housing policy we suggest, as another illustration of the need for joined-up government, that NSW Health has an interest in the design and construction of new housing. The principles of Universal Housing Design (UHD), Appendix 1, have the potential to reduce costs inside the NSW Health system, particularly in high-cost hospital services.

One aspect of UHD is the absence of steps, shower hobs and other tripping hazards. When homes are neither designed for inclusion or not modified as the needs of residents change the medical costs , time off work and ongoing personal care commitments associated with falls in the home negatively


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impact on true costs of continuing to design and build homes with an insufficient regard to more complex definitions of sustainability.

Council believes that the high cost of health care would be substantially reduced were slips trips and falls within the home made less frequent by the absence of tripping hazards. Statistics on the medical associated costs of slips, trips and falls done Mary Potter-Forbes and Chris Aisbett can be accessed from the IMRC website.8

Further, the ambiance of a home unlimited by design, indeed an accessible and sustainable society (commercial premises, recreation facilities and environments) will benefit the mental health and well being of all.

NSW Health and the Minister for Health might, therefore, make legitimate comment on the debate around these issues affecting the mental health and regular injury of Australian residents, with the potential to reduce the cost of health care. (It is noteworthy that such health costs are likely to increase with the ageing of the population due to the higher incidence of slips, trips and falls by older people).

Similarly, this matter might be raised during negotiations with the Commonwealth. Issues discussed could include means to address mental health, or specific assistance to groups at risk (e.g. preventative health checks for people with intellectual disability) could likewise be addressed.

Conclusion

All people deserve to enjoy the best health possible. This is as true for people with disability as much as it is true for anyone. Equity of access to the health care systems of NSW must therefore be the cornerstone of all future decisions, funding and delivery of public health services in NSW. We believe the future directions identified by NSW Health are pivotal to achieving such equity.

People with disability will not be treated in an equitable manner, however, until the community as a whole accepts that to do so is an indicator of having attained the ‘decent society’ toward which our aspirations for social justice must lead us. Government services, health no less than any sector, must lead by example in a concerted, long term drive to reduce then eradicate systemic barriers that hinder equal access, participation and inclusion. NSW Health must pay particular attention to systemic barriers where they impact on the delivery of a high quality responsive health system.

Our comments and recommendations indicate an approach that has merit in considering how to further reduce barriers, including those of stereotyping and differential treatment of people with disability, currently commonly experienced by people with disability engage with the health systems of NSW.

8 http://www.irmrc.unsw.edu.au/Publications/centrereports.aspDisability Council of NSWSubmission on Fit for the futurePlanning for the Future: NSW Health 2025

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We offer these observations as a supportive and encouraging contribution to the commendable strategic thinking evidenced by NSW Health in “Fit for the future”. Council looks forward to continuing liaison, through partnerships and dialogue, with NSW Health as it strives to modernise the health system, equipping it with the culture, personnel, skills and performance levels that will be required to be responsive and appropriate to the needs of all in the community, now and in the decades ahead.


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Appendix 1

Universal Housing Design Principles

The Universal Housing design principles have been summarised by the Australian Network for Universal Housing Design (ANUHD) as follows:1. There is a clearly discernable accessible path of travel from the front

boundary or car park and throughout the entry level of the dwelling. 2. The entry level has a living and food preparation area, bathroom, WC and

bedroom, all of which can be used by a person in a wheelchair. 3. All rooms, when furnished or fitted out, allow for adequate circulation

space for a person using a wheelchair. 4. All doorways and corridors are wide enough to allow a person using a

wheelchair to manoeuvre into and out of rooms. 5. Door furniture, switches, controls and outlets are within reach of and can

be used by all. 6. There is potential for future adaptation to a dwelling with two or more

levels for vertical access by a person using a wheelchair. 7. Walls and ceilings are reinforced where assistive devices may be

attached.


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Documents

Developing a Sustainability Charter for Australia€¦ · Web viewWhile not disregarding the experience of impairment and illness in the lives of some people with disability, our