THE PRODUCTIVITY COMMISSION (Productivity Commission 2004) has nominated nationally coordinated health sector reform as one of two top priorities (along with natural resource management) for extending the industry reform agenda under the aegis of National Competition Policy. This is in recognition of the importance of these areas for the wellbeing of Australians, and the level of resources they will require in future years. The Commission states that "an independent review of Australia's health system as a whole is a critical first step in achieving cooperative solutions to deep-seated structural problems" (p. XI). The fragmentation in health system governance that results from the nationalstate split is mirrored in the lack of coordinated care at many levels throughout the system. The Commissions proposal has been welcomed by many in the health industry, no doubt with some nervousness, because of the broad and deep conviction that something has to change in the apparently intractable problem of split funding responsibilities.
"Todays health-care delivery systems are not organized in ways that promote best quality. Service delivery is largely uncoordinated, requiring steps and patient 'hand-offs' that slow down care and decrease rather than improve patient safety" (OECD 2004). Improving care coordination is high on the list of issues to be addressed in any reform of the health sector. This issue of the journal features a collection of papers which address the sometimes jagged 'seams' in the current system. They offer insights into some of the consequences of the structural problems the Productivity Commission would like to see addressed, and document an energetic search for methods of enhancing the effectiveness of health care.
There have been many positive contributions to care coordination. Kroemer and colleagues (page 266) explain how a collaborative approach to rehabilitation for selected older patients (who were otherwise targeted for long-term residential care) succeeded in getting most of them home. Middleton and colleagues (page 255) report that while getting discharge summaries to GPs is still a problem, patients are more informed about how long they'll stay in hospital and generally feel ready for discharge.
However, other attempts suggest that care coordination and integration may depend on broader structural reform. Brand and coauthors (page 2 75) found that an intervention aimed at preventing readmissions of patients with chronic disease may have been too small and insufficiently integrated with existing care models to be effective. They urge those who fund experimentation with new models to set aside funding for larger-scale evaluation studies as well. Nagree and colleagues (page 285) demonstrate that a focus on reducing Emergency Department attendances by emergency patients who could have been treated by a GP is unlikely to have a significant impact on ED workloads in Perth hospitals, and may not save money. Dow (page 260) documents the often difficult experiences of carers of patients discharged early as part of a 'bed substitution' approach to rehabilitation. In the area of mental health services, Buchan and Boldy (page 292) found that GPs, psychiatrists and administrators suggested that an agreed definition of the scope of primary care psychiatry, methods to improve GP access to mental health services, and better communication and education were required to improve service integration.
These studies illustrate some of the difficulties we have in navigating the largely artificial boundaries created among the various health sectors. There has been mixed success in implementing the required care coordination mechanisms, such as standardised assessment and admission tools, system-wide pathways and other collaborative initiatives that cross existing service sector boundaries. …