An electronic publication from the Australian Indigenous HealthInfoNet
Issue 8, July 2000 - October 2000 : ISSN 1329-3362
Theses
Field, P. (1998). A review of Territory Health Services' planning processes for primary health care services in Central Australia. Unpublished Mater of Public Health thesis, University of Sydney, Sydney.
Salisbury, C. (1997). A health service and community partnership utilitising action research for the development of Aboriginal and Torres Strait Islander mental health services. Unpublished Doctor of Public Health thesis, University of Wollongong.
Field, P. (1998).
This report presents a review of the current Territory Health Services (THS) planning processes for primary health care (PHC) services in Central Australia. The broad aim of the review is to inform the urban and remote PHC planning processes in order to maximise its effectiveness. This work is concerned with the premise that sound planning processes are essential to develop and support solutions to health problems. The executive summary presents the conclusions of the review and the recommendations.
The current THS operational or business planning process was introduced in August 1996. The THS Corporate Plan 1996-99 that provides strategic direction for this process was completed in September 1996. The data collection for this review was undertaken during October and November 1997. Thus, at the time of data collection, all areas of THS had been required to develop and utilise business plans for more than 12 months.
The methodology is predominantly qualitative, with data collected from staff groups and individuals using semi structured interviews. The data was collected from discussions in environments that ranged from formal staff meeting settings to very informal "afternoon tea" settings in remote area health centres. At times, staff comments have been presented verbatim in order to accurately reflect staff views. The original scope of the review was extended by themes and issues identified by the staff. I considered these emergent views to be very important, and relevant sections have been included to address these issues. A small amount of quantitative information is presented in relation to numbers of staff and groups interviewed. These have been stratified according to professional, managerial or operational staff categories and Aboriginality.
The environment and the geography of the Central Australia region is important for the context of the review. The Alice Springs Remote Health Services'(ASRHS) health centres are widely dispersed with relatively few, isolated staff. Travel continues to be hazardous and face to face communication with managers infrequent. Because of their isolation from other urban centres, health professionals have a higher degree of professional isolation than their metropolitan colleagues.
The implementation of a formal corporate and operational planning process by THS is consistent with contemporary management best practice. The research found that staff are generally supportive of the process, which has the potential to help to focus and prioritise services according to need. Because of this it is important that the staff's energy and enthusiasm is captured and utilised.
Central Australia is a complex environment in which to work. It is geographically large and sparsely populated. Overall, a third of the population is Aboriginal. Remote area people are predominantly traditionally orientated Aborigines with some 12,000 people living in over 100 communities over 500,000 square kilometres. Health Centres are staffed by racially and professionally mixed teams. Because of their isolation, and expertise in this particular environment, it is essential that staff input is facilitated and valued throughout the planning processes.
This review identifies many difficulties encountered with the current process. All the difficulties identified by staff need to be carefully considered. The initial information from staff was presented to the Central Australia Regional Executive in November 1997 by way of an interim report. As a result of this planning proformas were modified and assistance provided for remote area staff to develop their plans. However, staff feedback is that these changes added to the confusion. An extra form was added, and the person with the task of assisting with the development of plans had no urban or remote PHC experience, and little knowledge of planning processes. The major issues that emerged from this review are that the planning process is top down, complex and lacks intra- and intersectoral collaboration and co-ordination. Staff reported that processes were imposed with a minimum of preparation and no extra resources. The involvement of staff varied from little or none, to a high degree of involvement. Staff involvement is one of the main themes of the review and is explored in detail in the sections 4.2.
The THS Corporate Plan (THS, 1996b) describes a process of business planning that is easy to understand, action oriented and achievable. The THS Corporate Plan makes the point that business plans should guide day to day activity, and include strategies, actions and performance indicators that are the basis of annual review and program/service evaluation. The Plan also specifies that, 'all planning should involve community leaders, other service providers and clients or patients (THS, 1996b, p27).' This review found little evidence of any of these stipulated components in the THS planning processes.
THS business plans developed at this time did not result in quality effective documents that informed practice, focused activities and ensured a common understanding of services. Staff expressed a high degree of frustration about the initial planning processes. A major factor that contributed to the dissatisfaction of the planning process was the subsuming the work unit plans into section or branch plans. Much individual detail was lost in this process. It is essential that each work area develop a plan that reflects the function of their area rather than trying to summarise the work of other units. For example, a branch is concerned with setting directions and supporting staff to ensure that they have the skills and resources to provide the service. These differences should be reflected in the business plans. Appending their plans to the branch plan can reflect the activities of work units.
Aboriginal staff were found to be of greatest disadvantage in the THS business planning process. They were rarely given the opportunity to be involved in developing business plans. The majority interviewed did not have any prior knowledge or understanding of the process. Despite this, the interviews clearly demonstrated their interest and enthusiasm for planning.
Remote area staff often identified the lack of community involvement in the planning process. As specified by the THS Corporate Plan, community involvement is an underpinning principle of PHC and an essential component of planning. However, it is not current practice in any of the health services that took part in this review. To the credit of individual staff members some remote area health centres have involved the community in local health services' planning.
Intra- and intersectoral collaboration are also important principles of PHC but were not included in THS planning processes. Lack of co-ordination and collaboration can only have negative consequences for health care services and client outcomes.
Multidisciplinary team involvement was not evident as a consistent feature of current THS planning processes. A strong principle of PHC is that health care services need contributions from various professional groups to adequately meet the needs of clients. A single professional view will be biased and is unlikely to acknowledge and value alternative methods of service delivery.
The process of implementation and monitoring of business plans is very ad hoc. The THS Corporate Plan and Brandon (1997) state that the THS staff performance monitoring or Work Guidance program is integral to business planning and should link into the monitoring process. For this to be effective staff would report on the business plans as part of the Work Guidance process. However this review found that few staff had been involved in any performance monitoring or Work Guidance process.
A few areas referred to their plans during work area meetings and the staff involved found this process useful as a method for maintaining their focus and reviewing their progress.
Performance indicators (PIs) that are precise and measurable need to be developed for monitoring to be effective. These can include qualitative, social and cultural aspects of care, process and quantitative measures. Developing sound performance indicators requires a high degree of skill. There has been no education or training in the development of sound PIs.
A Treasury driven evaluation process was undertaken in early 1997. This required staff to report on program outcomes. Staff had no preparation for this process and many of the programs had no defined objectives or methods for measuring outcomes. As a result staff found the process ineffectual and time consuming. There is no other systematic THS evaluation process.
Budgetary information has not been available to link with the planning process. This makes it impossible to plan programs with a realistic financial basis. Because plans are not routinely monitored, there is no information available to assess the effectiveness and efficiency of resource allocation.
Funding and budgetary information are integral to sound planning. Resources need to be according to output, outcomes and demonstrated need and must be constantly reviewed and adjusted. Most importantly staff must have budgetary information so that they can plan appropriate service delivery.
Sound communication is very important in any organisation. The complex nature of PHC services in Central Australia makes the development of well considered communication processes essential. One way of achieving this is to involve staff in deciding what information they need. Staff stated that the volume of information that they received blocked rather than facilitated communication. Information flow needs to be rationalised so that staff receive relevant timely information to support their service delivery.
Timely and appropriate communication in remote areas is very difficult with management personnel, District Medical Officers, (DMOs), and Allied Health Professionals (AHPs) based in town. The decentralised area management model as proposed by Wakerman, Bennett, Healy and Warchivker (1997) would facilitate communication. A major strength of this model is accessibility of a range of skills that have the potential to meld into a cohesive team under the right management. Many of the recommendations of this review are cost neutral but require a restructuring of current services and management positions. The potential benefits considerably outweigh the difficulties that will be encountered in implementing this change. Managers and a range of health professionals working together can only improve communication, and facilitate a multidisciplinary team approach. Involvement of the community in planning will also be facilitated with managers and health professionals living in the area in which they provide services. It is important that the model adopted in remote areas includes the re classification of centralised management positions otherwise the potential for professional tensions and problems brought about by dual management and the retaining of professional boundaries is high.
Recommendations of this report have been categorised, in line with the findings of the review, as:
Accessibility, format and process
- Communication
- Staff capacity
- Intra- and intersectoral processes and community involvement
- Budget and resource allocation
- Monitoring and evaluation
Salisbury, C. (1997).
Legge (1992:97) argues for a recognition that 'health is created beyond the health system and there is a need to ensure that health problems are seen from the perspective of the local community rather than as technical problems for health professionals to define or treat.' The improvements in Aboriginal and Torres Strait Islander health that are badly needed in Australia create an imperative to develop Indigenous participatory planning processes in health services. It is necessary to identify processes which facilitate involvement and ownership of a participatory process, thereby ensuring an Indigenous perspective is brought to bear on health problems.
The aim of this study was to examine the effects of an action research partnership between the Tweed Valley Health Service (TVHS) and the Aboriginal and Torres Strait Islander Mental Health Services. It was proposed that the adoption of Labonte's (1989) view - that empowerment means to have increased capacity to define, analyse and act upon one's problems, in an action research partnership between the local Aboriginal and Torres Strait Islander community and TVHS - would assist in operationalising Indigenous community participation in TVHS planning. To achieve this type of partnership the health service had to be willing to enter the partnership and to give the authority to the Aboriginal and Torres Strait Islander Health Outcome Council to seek and trial solutions on Aboriginal and Torres Strait Islander Mental Health matters. This represents a structural change and a sharing of power. Key outcomes were deigned as the extent to which the re-organised services proved to be acceptable and utilised by the local Aboriginal and Torres Strait Islander population. Outcomes were operationalised through measures of service utilisation and consumer satisfaction with accessibility, process and outcomes.
The study trailed participatory action research as a method for Indigenous participation in Mental Health Service planning and development in a complex medical setting. The method facilitated the accommodation of different cultural perspectives on health and research and the operationalisation of Indigenous participation in health service planning and development.
The TVHS and Aboriginal and Torres Strait Islander partnership in service development and delivery resulted in a set of components that were considered essential for the provision of an effective Aboriginal and Torres Strait Islander Mental Health Service:
1. Acknowledgement by the TVHS that life is experienced as stressful for Aboriginal and Torres Strait Islanders with grief and loss being experienced more frequently by members of the Aboriginal and Torres Strait Islander community.
2. Acknowledgement by the TVHS that Aboriginal and Torres Strait Islander persons experience public health facilities as discriminatory and not culturally accepting.
3. The first point of contact with TVHS for an Aboriginal and Torres Strait Islander person in distress should where possible be with an Aboriginal and Torres strait Islander person available 24 hours per day and able to provide an outreach service.
4. The service must represent an Aboriginal and Torres Strait Islander solution with Aboriginal and Torres Strait Islander control.
5. The TVHS should provide a context that is accepting of Aboriginal and Torres Strait Islander people.
