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Tasmania’s Health Plan

Clinical Services Plan: Update Incorporating changes to ownership of the Mersey Community Hospital May 2008

For more information on Tasmania’s Health Plan visit www.health.tas.gov.au Department of Health and Human Services Table of Contents

Foreword 3

Executive summary 4

Introduction 8

Implementation commitments 9

Tasmania’s community and its health status 15 Tasmania’s population 15 The socio-economic and health status of Tasmanians 19 Implications for Tasmania’s health care system 21

Tasmania’s public acute hospital system 22 Introduction 22 The Royal Hobart Hospital 22 The Launceston General Hospital 23 The North West Regional Hospital (Burnie) and the Mersey Community Hospital 23

Principles for Tasmania’s health services 27

Progress since publication of the Clinical Services Plan 28 Inpatient activity 28 Emergency activity 28 Community-based services 29 Clinical Services Plan initiatives 29 Aligning the Department’s structure with service delivery objectives 30

The service capability framework 32 Principles 32 Cooperative service development and support 33 Statewide services – governance, funding and accountability 33 Applying the service capability framework to existing services 36

Specific service issues 41 Autologous bone marrow transplantation 41 Adult medical retrieval 41 Bariatric surgery 41 Cardiac electrophysiology 42 Hyperbaric medicine 42 Medical imaging 42 Pathology 42 Rehabilitation 43 Vascular surgery 44

Clinical Services Plan: Update 1 Integrated care centres 46 Commitment to develop purpose-built facilities for integrated care 46 Integrated care – a definition 46 The need for integrated care 46 Types of integration of health care 47

Efficiency and accessibility of hospital services 50 Introduction 50 Benchmarking Tasmania’s resources 50 Using resources efficiently – benchmarking length of stay 51 Using resources efficiently – potentially avoidable hospital admissions 52 Regional utilisation rates 53 Regional self-sufficiency 54 Equity of regional investment 55 Access to emergency department services 59

Predicting future demand 60

Meeting the needs of the community – the future service system 64 Introduction 64 Planning sub-catchments for the North West region 65 A single hospital for the North West region 65 Planning for an integrated service system in the North West region 66 Planning assumptions for the North and North West regions 69 Planned acute hospital activity, 2016–17 72 Planning outcomes for the North West Regional Hospital (Burnie) 75 Planning outcomes for the Mersey Community Hospital 76 Planning outcomes for the Launceston General Hospital 77 Planning outcomes for the Royal Hobart Hospital 78

Enablers of a sustainable service system 81 Clinical networks 81 Workforce 83 Stakeholder engagement and distributed governance 83

Glossary of abbreviations 85

Glossary of terms 86

2 Clinical Services Plan: Update Foreword

Last year, when I released Tasmania’s Health Plan and the documents that underpin it – the Clinical Services Plan and the Primary Health Services Plan – I said that it was time to ‘take the politics out’ of health care. I argued that it was time to make patients, along with the quality, safety and sustainability of the care they receive, our focus.

Four short months later another chapter in the shared history of politics and health was written with former Prime Minister John Howard’s intervention at the Mersey campus of the North West Regional Hospital.

Ownership of the Mersey Community Hospital was transferred from the Tasmanian Government to the Australian Government on 23 November 2007. Given its intended role in the coordination of hospital services in Tasmania, the Mersey’s change of ownership made it necessary to update the Clinical Services Plan.

The update that follows is not only the result of that work, but it also provides an opportunity to do much more than dwell on the change of ownership.

Indeed, it provides a chance to show that work is progressing on the implementation of Tasmania’s Health Plan with the majority of projects associated with it well underway.

It also allows new and updated information to be included to ensure the development of Tasmania’s public acute hospitals and related services is based on the most accurate data projections available.

This update incorporates specific goals and timeframes for implementation, and includes a number of recent initiatives being pursued by the new Australian Government.

These initiatives will significantly improve the availability of acute health services to our community and need to be taken into account as we plan the growth and development of Tasmania’s public acute hospitals.

While the Tasmanian Government believes the 2007 Clinical Services Plan represents the best approach to meeting the health needs of all Tasmanians, this update re-endorses the principles of access, quality, safety and sustainability that underpinned the Plan.

It also sets out an approach to working constructively with the Mersey Community Hospital to ensure the services it provides in the future are integrated as much as possible with other public health care services on the North West Coast.

I am confident that this Clinical Services Plan update, as part of Tasmania’s Health Plan, provides a sound basis for the future of health care in this State. I look forward to its continued implementation and improvements in our health services in coming years.

Lara Giddings Minister for Health and Human Services

Clinical Services Plan: Update 3 Executive summary

Tasmania’s Health Plan, published in May 2007, incorporated a Primary Health Services Plan and a Clinical Services Plan which defined the future configuration of Tasmania’s public acute hospital services. Since that time, a number of changes have occurred, including but not limited to the purchase of the Mersey Community Hospital by the Australian Government.

The Tasmanian Government believes that the changes proposed in the 2007 Clinical Services Plan represent the most appropriate approach to meeting the health needs of the community, particularly in the North West region of Tasmania. Nevertheless, the changes that have occurred since the 2007 Clinical Services Plan was published require it to be updated.

This Clinical Services Plan update reviews progress since the Clinical Services Plan was published, addresses the impact of a number of Commonwealth and State initiatives and incorporates data modelling based on the most recent service utilisation and demographic data available.

Planning has continued on the redevelopment of the Royal Hobart Hospital (RHH) and on the development of an Integrated Care Centre (including a renal dialysis unit) in Launceston. Funding commitments have been made for a number of new services including a fifth linear accelerator for the State, two magnetic resonance imaging units (one at the Launceston General Hospital, the purchase of which has been approved, and one in the North West region) and a positron emission tomography (PET) scanner at the RHH. A review of bone marrow transplantation services has been concluded and the results are being implemented, and a number of other service reviews are progressing in accordance with commitments made in the 2007 Clinical Services Plan. The Department of Health and Human Services (the Department) has been restructured to enable it to meet the needs of the community more effectively and efficiently.

The higher prevalence of chronic disease and poorer health of Tasmanians compared to other Australians are confirmed in recent data.

The public acute hospital system continued to provide a high level of service to the community in 2006–07 with growth in both inpatient and emergency department presentations.

In this Clinical Services Plan update, the Tasmanian Government endorses the key principles established for Tasmania’s health services in the 2007 Clinical Services Plan. Service accessibility is a key goal, providing services can be delivered safely, effectively and at acceptable cost locally. Where services are not sustainable locally, they will be coordinated to optimise access for all Tasmanians, regardless of where they live.

With a population of less than 500,000 people, some services (e.g. cardiac surgery) can only be provided on a statewide basis from one site in Tasmania. Other services are provided as regional referral services by the Launceston General Hospital (LGH) to communities in the North West region. The 2007 Clinical Services Plan principles for regional referral and statewide services are endorsed and clarified. The LGH is recognised as the major referral hospital for the North West region. The requirement for the RHH and the LGH to be funded for the provision of necessary outreach services and to demonstrate accountability to the stakeholders in the outreach region for the quality and accessibility of those services is affirmed.

A number of specific service commitments are made in this Clinical Service Plan update. A decision about the introduction of cardiac electrophysiology services will be made by June 2010. The need to invest in rehabilitation services is recognised widely and the Department will publish an implementation plan for rehabilitation services by February 2009. Specific arrangements will be made to ensure that vascular surgery services are accessible to residents across the State while maintaining a sustainable statewide service.

4 Clinical Services Plan: Update The commitment in the 2007 Clinical Services Plan to develop integrated care centres (ICCs) provides a unique opportunity for the Tasmanian health care system to develop new models of care which span the interface between hospital and community services. The Department will finalise its policy and planning framework for ICCs by July 2008, enabling progression to a detailed model of care and facility planning. Work has commenced with the Australian Government to determine the best way to progress the planned GP Superclinics in Clarence/Sorell, Burnie and Devonport in the context of the Tasmanian Government’s planned investment in ICCs.

Review of resource and activity data suggests that there are continuing opportunities to improve the utilisation of resources in Tasmania’s public acute hospitals. There is a relatively high number of public hospital beds across the State (including a relatively high number of beds in small rural hospitals), but a low number of public hospital separations, a relatively low number of patient bed days per annum, a high average length of stay and a higher-than-average cost weight per casemix-adjusted separation. There was a modest reduction in 2006–07 in the number of admissions of patients with conditions which are classified as potentially able to be managed on a non-admitted basis.

If benchmark lengths of stay were achieved, more than 30 hospital beds would be freed up across the State. The Department and the public acute hospitals will continue to develop strategies to achieve best practice in length of stay across all diagnostic categories.

A review of regional access to public acute hospital resources suggests that access is higher in the North West and North regions compared with the South region, but when public and private access is considered residents of the South region have significantly better access to hospital services than residents of the North and North West regions. It is likely that differential investment will be required to improve access by residents of the North West, in particular, to public acute hospital services, although options to invest in non-admitted services and to encourage greater levels of private service provision also should be explored.

Most Tasmanians access public acute hospital services in the region in which they live. In the North West, 76 per cent of public hospital separations were provided by the North West Regional Hospital (Burnie or Mersey campuses or via public contracts or to dialysis patients treated in Burnie by the LGH) in 2006–07. Fewer than 6 in 100 patients from the North West region who received public hospital inpatient care in the State in that year received care from the RHH. The LGH provided almost 88 per cent of public hospital separations within Tasmania utilised by residents of the North. There was a high level of self-sufficiency for public hospital services in the South of the State.

There are no proposals in this Clinical Services Plan update that will reduce self-sufficiency for Tasmania’s residents. Over time, opportunities to improve self-sufficiency in the North West by increasing the range of services delivered locally or on an outreach basis should be captured.

Some clinicians and managers in Tasmania’s acute public hospitals are concerned that the distribution of resources between the hospitals is inequitable. This is a complex issue that requires consideration of a range of factors including region-specific costs, the costs of teaching and training and the complexity of patient care. The Department recognises that it is an important issue which requires resolution. The Department will complete a detailed study of cost modelling and resource allocation benchmarks to establish a mechanism to ensure equity in future resource allocations.

There are high levels of demand for emergency department services in Tasmania, particularly in the North West and North of the State. The increased demand in these regions correlates with the reduced access to GP services experienced by these communities. The Department will work with the Australian Government, Divisions of General Practice and other relevant organisations to develop a ‘whole-of-state’ strategy for general practice with the objective of improving access to general practitioners, particularly in the North West region.

Clinical Services Plan: Update 5 Demand for public acute hospital services, particularly for older people, is predicted to grow across the State by 30 per cent between 2006–07 and 2016–17. A requirement for an additional 67 same day beds and an additional 345 multi-day beds across the State by 2016–17 is predicted.

There will be a need for more operating theatres, but there is sufficient capacity within current and planned facilities to accommodate this demand.

Emergency department activity is projected to increase by more than 25,000 presentations per year by 2016–17. There will be a need for increased physical capacity, particularly at the LGH, to accommodate this demand unless it can be ameliorated through other strategies. This is being addressed by strategic assessment planning and announcements to upgrade the Department of Emergency Medicine at the LGH.

The 2007 Clinical Services Plan proposed a fundamental redesign of the public acute hospital services in the North West region with consolidation of high acuity services on the Burnie campus of the North West Regional Hospital (NWRH) and consolidation on the Mersey campus of high throughput day surgery and specialist aged care and rehabilitation services. The acquisition of the Mersey Campus of the NWRH by the Australian Government has led to this review.

Both the Australian and Tasmanian Governments have expressed a firm commitment to work together to develop an integrated and sustainable service system for residents of the North West.

This Clinical Services Plan update includes two potential models for services in the North West, which will need to be refined when the Australian Government has confirmed the range and volume of services that will be provided by the Mersey Community Hospital. In the context of current circumstances, the Tasmanian Government prefers Model 1, which is very similar to the service model proposed in the 2007 Clinical Services Plan and which designates the Mersey Community Hospital as a provider of day surgery and specialist aged and rehabilitation services, together with low risk obstetric and emergency services. In addition, the revised model provides for the Mersey Community Hospital to admit medical and paediatric patients with low complexity conditions, supported by a high dependency unit.

Model 2, although not preferred by the Tasmanian Government, reflects its understanding of the intention of the Australian Government to develop the Mersey Community Hospital as a full service community hospital.

Under both models the NWRH (Burnie) will continue to provide the range of services outlined in the 2007 Clinical Services Plan, including a regional intensive care unit.

Both models predict significant growth in overnight admissions to the NWRH (Burnie) with bed growth to either 163 or 183 beds, depending on which model is implemented. Both models also predict modest growth at the Mersey Community Hospital – to either 95 or 118 beds. The number of patients treated at the Mersey Community Hospital is approximately equal under both models, but Model 1 provides a greater focus on same day patients.

The Australian Government is seeking a religious and charitable or private sector organisation to operate the hospital as a full service community hospital. The Tasmanian Government believes that a full service profile as provided for in Model 2 is unlikely to be sustainable. If the new operators are unable to deliver health care services of an acceptable range and quality, the Tasmanian Government would only consider resuming responsibility for the hospital on the basis that Model 1 was implemented.

6 Clinical Services Plan: Update It will be important for both levels of government to commit to delivering an appropriate range and volume of services and to demonstrate appropriate accountability to the community for the provision of these services. A range of measures including services by type and volume, trends in service complexity and trends in regional and sub-regional self-sufficiency can be used as a basis for monitoring performance and demonstrating accountability to the community. The Tasmanian Government will seek the Australian Government’s agreement to a robust performance monitoring and reporting framework based on these and other appropriate measures for the Mersey Community Hospital.

While some stakeholders consider that a single site regional acute hospital in a ‘neutral’ geographic position would resolve the sustainability problems experienced by public acute hospital services in the North West, a range of factors would need to be considered in relation to that proposal. Should the Tasmanian Government decide to progress the development of a single site regional hospital in the future, a full planning assessment of the best location for that hospital and the potential operational benefits that would be achieved should be conducted. In the absence of identified capital for such a development, this Clinical Services Plan update assumes that both the NWRH (Burnie) and the Mersey Community Hospital will continue to deliver inpatient services from their current sites.

Significant growth is predicted for the LGH, with bed requirements increasing by approximately 20 same day and almost 100 multi-day beds in both models.

Planning for the RHH is continuing, with a growth in separations of 31 per cent expected. Increases of 33 same day beds and 130 multi-day beds will be required to meet this demand. The redevelopment of the RHH also provides a unique opportunity to develop innovative new models of care supported by purpose-built physical facilities.

This Clinical Services Plan update reiterates the importance of Tasmania’s clinicians and health care managers working together to ensure that service development initiatives in specific regions do not compromise the sustainability of existing services or the development of new ones of benefit to the State as a whole.

A large number of specific commitments are made in this Clinical Services Plan update to provide a basis for monitoring progress and ensuring transparency and accountability of implementation.

Clinical Services Plan: Update 7 Introduction

Since the Clinical Services Plan was published in May 2007, a number of changes have occurred that will impact on the future of Tasmania’s acute hospital system, including: • ownership of and operational responsibility for the Mersey campus of the NWRH have moved from the Tasmanian Government to the Australian Government, which has announced that it intends to seek a religious and charitable or private sector organisation experienced in managing public hospitals to operate the Mersey Community Hospital as a public hospital from 1 July 2008; • the following commitments have been confirmed as Australian Government policy: – $15 million for GP Superclinics in Clarence/Sorell, Burnie and Devonport. Work has begun with the Australian Government to determine the best way to progress these in association with the ICCs recommended in the Clinical Services Plan; – $7.7 million for an additional radiation oncology service in the North or North West of the State; – $3.5 million in support of a PET scanner at the RHH; – $15 million for an ICC in Launceston; – $10 million for patient transport services including the purchase of community buses; and – two Magnetic Resonance Imaging (MRI) services approved for Medicare-eligibility purposes in Launceston and the North West; • the Department has announced the purchase of an MRI for the LGH; • considerable progress has been made in planning the redevelopment of the RHH; and • various specific reviews have been completed, including reviews of statewide retrieval services and autologous bone marrow transplantation services, and recommendations for service redesign and development have been made.

In addition, the Australian Government has made a number of commitments to address health issues nationally, creating significant opportunities for Tasmania: • an Elective Surgery Waiting List Reduction Plan incorporating immediate and longer-term actions to improve access to elective surgery. Significant additional funding will be available to enable an elective surgical blitz in Tasmania. The Elective Surgery Waiting List Reduction Plan provides for patients to elect to be referred to hospitals where waiting times are shorter. Public hospitals will be able to purchase additional capacity from private hospitals if necessary; • national investments in aged care, including: – 2,000 additional transition care places for frail aged people waiting for an aged care place, which will help free up public hospital beds, complementing a transition care program jointly funded by the Australian and Tasmanian Governments; – $300 million in low-interest loans to build or expand residential and respite facilities in areas of need; – 600 Community Aged Care Places; – 400 Extended Aged Care at Home packages (including 200 dementia-specific); and – 800,000 practice nurse home visits.

It is timely to update the Clinical Services Plan to take account of the initiatives that have been announced since the Plan was first published.

This update has been informed by a full review of the most recent activity and demographic data available as well as consultation with representative clinicians, managers and other stakeholders across the State.

8 Clinical Services Plan: Update Implementation commitments

This Clinical Services Plan update defines a large number of commitments by the Tasmanian Government and in particular the Department to effect changes to the range of health care services and to the way some services are delivered in Tasmania’s public acute hospitals.

It defines projections for activity through to 2016. These projections will facilitate annual and three- yearly planning of activity and models of care. In addition, it defines a number of actions that need to be taken in relation to service development and service governance and the timeframes within which these commitments will be effected. These will form the basis for a detailed implementation plan to ensure that the Clinical Services Plan serves its intended function as a blueprint for the development of Tasmania’s acute hospital system.

The following commitments are made in this Clinical Services Plan update:

Implementation commitment Timeframe 1 The Department will revise and publish the population and demand projections in When ABS data this Clinical Services Plan update when population projections based on 2006 census are available data are published by the Australian Bureau of Statistics (ABS), recognising that while those population and demand projections will be more accurate than those available at present, the underlying trends in demand which form the basis for the Plan will not change. 2 The Tasmanian Government re-endorses its commitment to the principles defined Ongoing in the 2007 Clinical Services Plan and in particular to: • service accessibility where services can be delivered safely, effectively and efficiently; and • designing Tasmania’s public health services to ensure their sustainability. 3 The Department will: By December • complete the business case for the redevelopment of the RHH (including an ICC); 2008 • work with the Australian Government to: Commence – progress planning for an ICC (including a renal dialysis service) in Launceston immediately and a radiation oncology unit in Burnie or Launceston; and – progress the installation of MRIs at the LGH and in Burnie, and a PET scanner at the RHH as a priority; • complete the redevelopment of the LGH emergency department; By June 2010 • publish an implementation plan for a sustainable medical retrieval service; By June 2008 • complete a transport strategy to enable the development of a comprehensive, By June 2008 coordinated service that is client-focused and timely and provides clinically appropriate transport options; • complete a patient accommodation strategy; and By June 2008 • finalise implementation of statewide services for bone marrow transplantation By December 2008 and vascular surgery, including identifying a specific statewide services budget and facilitating agreement about the extent of outreach services and the role of LGH clinicians. 4 The Department endorses and clarifies the following principles for regional Ongoing referral and statewide services: • a patient-focused, system-wide approach will be taken, based on the needs of all Tasmanians. Services will not be designed or developed around the needs of individual clinicians, individual regions or individual hospitals; • critical clinical inter-dependencies will be taken into account when planning the location of regional and statewide services; • funding to enable regional and statewide services to fulfil their additional responsibilities (e.g. to enable the provision of outreach services) will be provided as appropriate, through funding streams independent of normal hospital budgets;

Clinical Services Plan: Update 9 Implementation commitment Timeframe • regional and statewide services will be required to participate in the usual Ongoing clinical and management quality and accountability processes that apply at their host hospital; • regional and statewide services that are provided with additional infrastructure funding to support an outreach role also will be required to account for their performance to their broader communities of interest, addressing issues such as accessibility and outcomes of care across the State; • most statewide services will continue to be located at the RHH because it has the highest level of infrastructure, necessary associated services and access to important non-health organisations that aid in quality service provision and attraction and retention of professional staff for those types of services; and • if a statewide service does not depend on critical internal or external relationships that are more achievable at the RHH, the service may be located at the LGH. 5 The Department will implement mandatory policies and procedures regarding the By October 2008 introduction of new services and technologies to Tasmania’s public acute hospitals. These policies and procedures also will cover the recruitment, credentialling, and scope of clinical practice of senior clinical staff. The objective will be to ensure that recruitment and service development initiatives of individual hospitals do not jeopardise the sustainability of existing services; do not undermine the planned development of services in other regions; and are not likely to lead to inappropriate pressure in the future for the development of complex services where these are likely to be unsustainable. 6 The Department will ensure that, where feasible: Ongoing • arrangements for outreach services are made between hospitals rather than clinical units or individual clinicians; and • the LGH assumes a more formal and comprehensive regional support role to the North West region. Services which are viable only on an outreach basis in the North West region will be provided by arrangement with the LGH where possible, rather than with individual clinicians or the RHH. 7 The Department will develop and implement standard governance, funding and By July 2010 accountability arrangements for regional and statewide services, commencing with the following services: • adult and paediatric cystic fibrosis; • bone marrow transplantation; • cancer; • specialist cardiology; • infectious diseases; • neonatal intensive care, paediatric intensive care, neonatal and paediatric retrieval; • renal medicine; and • vascular surgery. The allocation to a hospital of funding for outreach services will carry with it responsibility to ensure the quality and reliability of those services and to demonstrate accountability for service accessibility and quality to providers and consumers from the outreach areas. The performance management framework for each hospital chief executive officer will incorporate accountability for ensuring that statewide service responsibilities are fulfilled. 8 The Department will oversee the development and implementation of a plan for the Complete bariatric provision of bariatric surgery by the RHH and will develop an integrated statewide surgery plan by multidisciplinary strategy for the management of patients with morbid obesity. January 2009 Complete integrated plan for the management of morbid obesity by December 2009

10 Clinical Services Plan: Update Implementation commitment Timeframe 9 The Department will complete a feasibility study into the development of cardiac By June 2010 electrophysiology services. 10 The Department will complete an expert review of hyperbaric oxygen therapy. By June 2009 11 The Department will complete feasibility studies of statewide services in medical By December 2009 imaging and pathology. 12 The Department will formalise the establishment of a rehabilitation and aged care Establish network network and publish an implementation plan for rehabilitation services. by August 2008 and publish implementation plan by February 2009 13 The Department will facilitate: By December 2008 • formal agreement between the LGH, the NWRH (Burnie) and the RHH on the scope of and accountability arrangements for vascular surgery provision to the LGH and the NWRH (Burnie); and • the development of formal protocols for the rapid transfer from the North and North West regions, direct to theatre at the RHH, of patients with time-critical vascular emergencies who are considered suitable for surgery. 14 The Department will convene a multidisciplinary ICC policy and planning group to Convene develop, consult on and finalise a policy and planning framework for ICCs that will immediately support a subsequent detailed model of care and facility planning. Complete policy and planning framework by July 2008 15 The Department will monitor and report annually on a range of benchmarking Commence data including lengths of stay and the rate of admissions for Ambulatory Care mid-2009 Sensitive Conditions. 16 As well as investing strategically in public admitted and non-admitted services for Ongoing the communities of the North West region, the Department will work with the private sector to determine ways to develop appropriate private sector inpatient services for the region’s communities. 17 The Department will establish a Health Industry Forum with participation by By February 2009 the private sector, and work with the private sector to facilitate the cooperative development of Tasmania’s health services for the overall benefit of the community. 18 The Department will monitor and publish regional utilisation rates regularly. Commence mid-2009 19 The Department will aim to maintain and improve equity of resource distribution between regions; accountability of hospitals for their efficient operation; and regional self-sufficiency of public acute hospital services. A detailed study of cost modelling and resource allocation benchmarks will be completed to establish a mechanism to ensure equity in future resource allocations. The Department’s aim will be to ensure that each hospital accesses a fair proportion of the State’s overall hospital investment and uses it efficiently for the best benefit of the community. Annual self-sufficiency targets will be established immediately in all regions and Commence performance against targets will be monitored and reported annually. immediately with annual reporting 20 The Department will collaborate with the Australian Government, Divisions of Complete by General Practice and other relevant organisations to develop a ‘whole-of-state’ December 2009 strategy for general practice. Key objectives of the strategy will be recruitment of general practitioners to the North West region to ensure more equitable access to general practice services; and the development of new models of support for general practice – including community-based and practice-based nurses – to ensure service sustainability.

Clinical Services Plan: Update 11 Implementation commitment Timeframe 21 The Tasmanian Government adopts the following principles to underpin planning Ongoing and delivery of hospital services in the North West region: • A balanced mix and appropriate volume of high quality public acute hospital services should be available to all residents of the North West region. Responsibility for providing these services will be shared by the Australian and Tasmanian Governments. • The Australian Government will be responsible for providing an appropriate range and volume of safe, high quality community hospital services to the residents of the referral area of the Mersey Community Hospital. The Tasmanian Government will license the Mersey Community Hospital in accordance with its usual licensing standards for private hospitals, but otherwise recognises that the Australian Government (or its delegates) will plan and be accountable for the role and service profile of the Mersey Community Hospital. • Residents of the Mersey Community Hospital referral region who need complex acute services which do not fit within the agreed service profile of the Mersey Community Hospital will be able to access such services through the State hospital system in Burnie, Launceston or Hobart. It will be important for the Mersey Community Hospital to deliver an agreed range and volume of services to its referral community, however, so that the Tasmanian Government can deliver the necessary complementary higher complexity services in a planned and equitable manner. • The Tasmanian Government will be responsible for providing an appropriate range and volume of public acute hospital services to the referral communities of the NWRH (Burnie). • Resources such as specialist staff; diagnostic services; theatre facilities; clinical governance functions such as audit; and purchasing functions could be shared between the NWRH (Burnie) and the Mersey Community Hospital, if such sharing would benefit the community and can be agreed between the Department and the operators of the Mersey Community Hospital. • Some services may be developed on a whole-of-region basis by agreement between the Australian and Tasmanian Governments. 22 The Department will develop a detailed clinical service profile for the NWRH By December 2008 (Burnie) in consultation and cooperation with the Australian Government and/or (but will depend the operator of the Mersey Community Hospital, with the objective of ensuring on timeframes sustainable services on a whole-of-region basis. for completion of a service plan for the Mersey Community Hospital) 23 The Tasmanian Government will seek to agree on a robust performance By December 2008 monitoring and reporting framework with the Australian Government to ensure that both the NWRH (Burnie) and the Mersey Community Hospital contribute equitably to the provision of an integrated health service for the region. 24 The Department will: • develop a short consultation paper defining the role and draft terms of By July 2008 reference of the Clinical Advisory Council and presenting more detail about the proposed number and type of clinical networks to be established; the roles and responsibilities of network members; methods of supporting networks; and principles for network operation; • establish a rehabilitation and aged care network; By August 2008 • establish a chronic disease network; By December 2008 • select the membership of and convene the Clinical Advisory Council; By October 2008 • ensure that fair and transparent arrangements are in place to fund and otherwise Ongoing facilitate the provision of adequate back-up and clinical support for clinicians who assume leadership positions, particularly those who are not full-time employees in the public hospital system;

12 Clinical Services Plan: Update Implementation commitment Timeframe • convene cardiac and renal forums. These forums will be presented with data and By December 2009 opinion about current and future service delivery challenges and opportunities and consensus will be sought about the most appropriate method to facilitate ongoing clinical interaction across the State. Convening regular planning forums may be an alternative to establishing ongoing clinical networks for these sub- specialty services; and • convene statewide clinical consultative meetings twice yearly in each of women’s Commencing by and children’s services; adult surgery; adult medicine; and critical care, trauma, July 2009 and emergency and retrieval services until formal ongoing networking structures ongoing until have been agreed on and implemented. networks convened 25 The Department will continue to work with the University of Tasmania and the Publish workforce tertiary and further education sector to develop and implement a long-term strategic plan by plan that links Tasmania’s health care education and workforce needs. The strategic December 2009 plan will link with this Clinical Services Plan update. In particular, the Department will undertake a workforce modelling exercise, based on the activity projections in this Clinical Services Plan update, to establish clear targets for workforce numbers in each health care professional category over the life of the Clinical Services Plan and identify key workforce risks and/or the need to redesign care pathways. 26 The Department will work with the chief executive officers of each public acute Develop clinical hospital to define explicit performance agreements incorporating targets for engagement clinical activity within agreed budgets and a requirement that they document a strategies by clinical engagement strategy and monitor and report on its effectiveness over time. December 2008

Summary of implementation commitments by date

Date Commitment Immediate Establish annual self-sufficiency targets, monitor and report Work with the Australian Government to: • progress planning for an ICC (including a renal dialysis service) in Launceston and a radiation oncology unit in Burnie or Launceston; and • progress the installation of MRIs at the LGH and in Burnie, and a PET scanner at the RHH as a priority Convene an ICC policy and planning group to develop a policy and planning framework Commence working with the private sector to determine ways to develop appropriate private sector inpatient services for the North West region June 2008 Complete a transport strategy Complete an accommodation strategy Publish an implementation plan for a sustainable medical retrieval service July 2008 Publish a consultation paper on the role and responsibilities of the Clinical Advisory Council and the clinical networks Finalise a policy and planning framework for ICCs to support a subsequent detailed model of care and facility planning August 2008 Establish a rehabilitation and aged care network October 2008 Implement mandatory policies for the introduction of new services and technologies and the recruitment, retention, credentialling and scope of practice of senior medical staff Select members and convene the Clinical Advisory Council December 2008 Complete the business case for redevelopment of the RHH Finalise implementation of statewide bone marrow transplantation and vascular surgery services Establish a chronic disease network In collaboration with the Australian Government and/or the operator of the Mersey Community Hospital develop a detailed clinical services profile for the NWRH (Burnie) Seek to agree on a robust performance monitoring and reporting framework with the Australian Government for the NWRH (Burnie) and the Mersey Community Hospital Document clinical engagement strategies for all acute public hospitals

Clinical Services Plan: Update 13 Date Commitment January 2009 Develop and implement a plan for bariatric surgery February 2009 Establish a Health Industry Forum to progress public/private cooperation Publish an implementation plan for rehabilitation services Mid-2009 Commence publishing public acute hospital benchmarking data Monitor and publish regional utilisation rates June 2009 Complete a review of hyperbaric oxygen therapy July 2009 Commence convening clinical consultative meetings twice yearly in areas in which clinical networks are not yet established December 2009 Complete a ‘whole-of-state’ general practice strategy Complete feasibility studies of statewide services in pathology and medical imaging Convene cardiac and renal forums Develop a strategic workforce plan Develop a statewide strategy for the management of patients with morbid obesity June 2010 Complete redevelopment of the LGH emergency department Complete a feasibility study for cardiac electrophysiology July 2010 Complete implementation of standard governance, funding and accountability arrangements for regional and statewide services

14 Clinical Services Plan: Update Tasmania’s community and its health status

Tasmania’s population Tasmania’s estimated resident population at June 2006 was 489,922 people.1

For planning purposes for its public acute hospitals, Tasmania has three main geographic regions consisting of the following Local Government Areas (Table 1):

Table 1: Tasmania’s planning regions

South North North West Brighton, Central Highlands, Break O’Day, Dorset, Flinders, Burnie, Central Coast, Circular Clarence, Derwent Valley, George Town, Launceston, Head, Devonport, Kentish, Glamorgan/Spring Bay, Meander Valley, Northern King Island, Latrobe, Waratah/ Glenorchy, Hobart, Huon Valley, Midlands, West Tamar Wynyard, West Coast Kingborough, Sorell, Southern Midlands, Tasman

There are some variations in the characteristics of Tasmania’s regional communities which impact on the health care needs of residents.

For example, the North and North West regions have a higher percentage of 5 to 14 year olds and of 55 to 74 year olds than the South, and a lower percentage of 15 to 34 year olds (Figure 1).

Figure 1: Tasmanian population age structure in 2006 9%9 North North West 8% 8 South 7%7 6%6 5%5

% of population% of 4%4 3%3 2%2 1%1 0 0 00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age group

Source: ABS Population by Age and Sex, Australia, 2006, cat. no. 3235.0.

Projections based on the 2001 census data suggest that over the planning period to 2016, Tasmania’s population will remain relatively stable with an overall increase of fewer than 1,000 people. The population of the South region is projected to increase by more than 3,000 people, the population

1 ABS 3235.0 Population by Age and Sex, Australia, 2006.

Clinical Services Plan: Update 15 of the North region is projected to increase by more than 2,000 people and the population of the North West region is projected to decrease by just fewer than 5,000 people (Figure 2). For reasons which are explained below, however, Tasmanian population projections to 2016 are likely to represent a significant underestimation of the actual population.

Figure 2: Changes in population by region 2006 to 2016

40004,000 South 30003,000 North 20002,000 Tasmania 10001,000 00 -1000-1,000 -2000-2,000 -3000-3,000 Change in population -4000-4,000 -5000-5,000 North West -6000-6,000

Source: ABS, DoHA. Projected Resident Population on 2001 statistical local area (SLA) Boundaries (ASCG 2001) as at 30 June 2002–2022.

In this report, Estimated Resident Populations at 30 June 2006 are used to calculate current service utilisation rates, but the convention of using official population projections based on census data has been followed for the purposes of estimating future demand. It should be noted that those official population projections are based on ABS projections which in turn are based on 2001 census data. The ABS projections significantly underestimated population growth between 2001 and 2006 – Tasmania’s actual population at 30 June 2006 was 489,922,2 whereas the ABS, on the basis of 2001 census data, had projected a 2006 population of 476,493. Clearly, that underestimation of population growth between 2001 and 2006 will result in a continuing underestimation of population projections to 2016. In addition, a number of positive economic factors may further exacerbate the underestimation of the 2016 population. For example, confirmed major developments in the mining and paper industries will result in new employment opportunities, which in turn may result in additional population growth beyond that predicted in 2001.

The main differences in the projected compared with actual population in 2006 were in children and in 30–50 year olds, which in terms of requirements for health services in the future will impact most on maternity and paediatric services.

The population projections used in this Clinical Services Plan update will require revision when the ABS projections based on the 2006 census are available. This will be simple to perform as the planning model is now well established. In addition it is important to recognise that while actual population numbers may vary from those predicted, the major trends described in this Clinical Services Plan update will not alter – the basis for the Plan, therefore, remains sound.

Implementation commitment 1 The Department will revise and publish the population and demand projections in this Clinical Services Plan update when population projections based on 2006 census data are published by the ABS, recognising that while those population and demand projections will be more accurate than those available at present, the underlying trends in demand which form the basis for the Plan will not change.

2 ABS Estimated Resident Population at 30 June 2006 (which was the most accurate available estimate of the actual population on that date).

16 Clinical Services Plan: Update The Local Government Area (LGA) populations which are projected to grow the most during the planning period are Kingborough (3,083), Meander Valley (2,193), West Tamar (1,372) and Hobart (1,270). The LGAs projected to decline in population include Glenorchy (-1,421), Burnie (-1,090) and Devonport (-1,088). Meander Valley and Kingborough populations are expected to experience the greatest percentage increase over the period, while Derwent Valley and West Coast are expected to experience the greatest percentage decrease in population (Table 2).

Table 2: Projected population growth by Local Government Area

Region LGA 2006 2016 Difference % North West Burnie 18,640 17,550 -1,090 -6% Central Coast 20,702 19,641 -1,061 -5% Circular Head 7,860 7,240 -620 -8% Devonport 24,048 22,960 -1,088 -5% Kentish 5,526 5,451 -75 -1% King Island 1,667 1,579 -88 -5% Latrobe 8,720 9,428 708 8% Waratah/Wynyard 13,452 12,892 -560 -4% West Coast 5,144 4,346 -798 -16% Total North West 105,759 101,087 -4672 -4% North Break O’Day 5,916 6,008 92 2% Dorset 7,288 7,000 -288 -4% Flinders 852 785 -67 -8% George Town 6,437 6,187 -250 -4% Launceston 62,368 61,356 -1,012 -2% Meander Valley 19,167 21,360 2,193 11% Northern Midlands 12 , 211 12,514 303 2% West Tamar 21,165 22,537 1,372 6% Total North 135,404 137,747 2343 2% South Brighton 13,294 13,580 286 2% Central Highlands 2,273 2,143 -130 -6% Clarence 49,892 49,645 -247 0% Derwent Valley 9,106 8,306 -800 -9% Glamorgan/Spring Bay 3,946 3,749 -197 -5% Glenorchy 43,708 42,287 -1,421 -3% Hobart 47,955 49,225 1,270 3% Huon Valley 14,432 15,291 859 6% Kingborough 31,319 34,402 3,083 10% Sorell 11, 326 11,743 417 4% Southern Midlands 5,841 5,987 146 2% Tasman 2,238 2,196 -42 -2% Total South 235,330 238,554 3,224 1% Grand Total 476,493 477,388 895 0% Source: ABS, DoHA. Projected Resident Population on 2001 statistical local area (SLA) Boundaries (ASCG 2001) as at 30 June 2002–2022.

Clinical Services Plan: Update 17 It should be noted that predictions of population decline in the West Coast and George Town are likely to be inaccurate because of the significant economic growth which is expected in these areas as a result of developments in the mining and paper industries.

Population changes across the three regions are predicted to follow a similar pattern by age group with particular increases in the number of people aged 60–69 (Figure 3).

Figure 3: Changes in population by age group and region 2006 to 2016

1200012,000 North 1000010,000 North West South 80008,000 60006,000 40004,000 20002,000 00 Change in population -2000-2,000 -4000-4,000 -6000-6,000 -8,000 -8000 0-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ Age group

Source: ABS, DoHA. Projected Resident Population on 2001 statistical local area (SLA) Boundaries (ASCG 2001) as at 30 June 2002–2022.

People aged 60 and over represent 20 per cent of the Tasmanian population currently. It is projected that in only 10 years this will increase to 30 per cent. People aged 70 and over represent 11 per cent of the Tasmanian population currently – this will increase to 14 per cent by 2016. The size of this age group is expected to grow in each region by approximately 30 per cent (Table 3).

Table 3: Growth in 70+ age group by region 2006 to 2016

% of the 70+ Region 2006 2016 Difference % growth population in 2016 North West 11, 66 0 15,147 3,487 30% 23% North 14,619 19,119 4,500 31% 30% South 24,404 31,403 6,999 29% 47% Grand Total 50,683 65,669 14,986 30% 100%

Source: ABS, DoHA. Projected Resident Population on 2001 statistical local area (SLA) Boundaries (ASCG 2001) as at 30 June 2002–2022.

18 Clinical Services Plan: Update The number of females of childbearing age is projected to decrease in all regions (Table 4).

Table 4: Change in females 15 to 39 age group by region 2006 to 2016

% population Region 2006 2016 Difference % growth 2016 North West 15,839 13,775 -2,064 -13 % 20% North 21,512 20,219 -1,293 -6% 29% South 38,244 35,598 -2,646 -7% 51% Grand 75,595 69,592 -6,003 -8% 100% Total

Source: ABS, DoHA. Projected Resident Population on 2001 statistical local area (SLA) Boundaries (ASCG 2001) as at 30 June 2002–2022.

These figures need to be taken into account in health planning – because older people have more chronic disease and greater need for health services.

The socio-economic and health status of Tasmanians Tasmania has a greater index of disadvantage3 than all other Australian states and territories other than the Northern Territory, correlating with the population’s high need for health care services (Table 5).

Table 5: Economic index of disadvantage, state and territory, 2001

State/territory Index of Disadvantage Australian Capital Territory 1078.7 Victoria 1014.6 Western Australia 1003.6 New South Wales 1000.5 South Australia 995.2 Queensland 991.5 Tasmania 969.7 Northern Territory 952.3

Source: ABS, Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA) 2001, cat. no. 2033.6.55.001.

Only seven LGAs in Tasmania score average or above average in socio-economic status (Northern Midlands, King Island, Meander Valley, Clarence, West Tamar, Kingborough and Hobart).

There are considerable opportunities to improve the health status of the Tasmanian community. For example, in 2006, the life expectancy at birth of Tasmanian males was 77.4 years, compared with an Australian average of 78.7 years. In the same period, the life expectancy at birth of Tasmanian females was 82.3 years compared with an Australian average of 83.5 years. Only residents of the Northern Territory have, on average, a lower life expectancy than Tasmanians (Table 7).

3 The Index of Disadvantage is based on a number of factors including income, educational attainment and unemployment. The index has a baseline of 1,000. A score above 1,000 indicates an area of socio-economic advantage and a score below 1,000 indicates an area of disadvantage. The level of deviation from 1,000 indicates the level of advantage or disadvantage.

Clinical Services Plan: Update 19 Table 6 shows that the standardised death rate in Tasmania in 2006 was the second highest of any Australian state or territory.

Table 6: Standardised death rate per 1,000 population, all causes by state and territory of usual residence, 2006

Sex NSW Vic Qld SA WA Tas NT ACT Australia Males 7.4 7.1 7.3 7.3 7.2 8.2 9.8 6.4 7.3 Females 5.0 4.9 4.9 5.0 4.7 5.6 7.4 4.8 4.9 Persons 6.1 5.9 6.0 6.0 5.8 6.8 8.7 5.5 6.0

Age standardised to the total Australian population as of 30 June 2001. Source: ABS, Deaths, Australia, 2006, cat. no. 3302.0.

Table 7 shows relative life expectancy for Tasmanians as a whole and Table 8 shows life expectancy at birth by sex and by region.

Table 7: Life expectancy at birth by sex and state and territory, 2006

State/territory Males Females Australian Capital Territory 80.0 83.9 Western Australia 79.1 83.8 Victoria 79.3 83.7 New South Wales 78.6 83.4 South Australia 78.6 83.6 Queensland 78.5 83.4 Tasmania 77.4 82.3 Northern Territory 72.1 78.1 Australia 78.7 83.5

Source: ABS, Deaths, Australia, 2006, cat. no. 3302.0.

Table 8: Life expectancy at birth by sex, Tasmanian regions, 2006

Statistical divisions Males Females Greater Hobart 77.7 82.3 Southern 77.0 81.5 Northern 77.1 81.4 Mersey-Lyell 76.5 82.9 Tasmania 77.4 82.3

Source: ABS, Deaths, Australia, 2006, cat. no. 3302.0.

20 Clinical Services Plan: Update Table 9 shows comparative death rates for selected conditions.

Table 9: Age-standardised death rates, selected causes of death, Tasmania and Australia, 2006

Cause of death Tasmanians Australians Malignant neoplasms 193.1 176.3 Diabetes mellitus 27.7 16.4 Mental and behavioural disorders 27.7 22.4 Diseases – nervous system 28.1 21.9 Diseases – circulatory system 221.3 201.9 Diseases – respiratory system 47.5 48.4 Diseases – digestive system 22.8 20.2 Accidents 30.6 24.9 Intentional self-harm 14.7 8.6

On average: • More Tasmanians report a long-term health condition than other Australians • More Tasmanians smoke than other Australians • Tasmanians eat fewer vegetables than other Australians • More Tasmanians are obese than other Australians • Tasmanians die at a higher rate than other Australians – the leading causes of death are diseases of the circulatory system and cancer

Source: ABS, Causes of Death, Australia, 2006, cat. no. 3303.0 and ABS, National Health Survey, 2004–05. Table 10 shows that the infant mortality rate in Tasmania in 2006, however, was the lowest of any Australian state or territory other than South Australia.

Table 10: Infant mortality rate per 1,000 live births, state and territory, 2006

Sex NSW Vic Qld SA WA Tas NT ACT Australia Males 5.7 4.7 6.6 2.7 4.7 4.8 8.1 5.2 5.3 Females 4.0 3.9 4.0 3.8 5.1 2.9 9.8 5.0 4.1 Persons 4.9 4.3 5.3 3.2 4.9 3.9 8.9 5.1 4.7

Source: ABS, Deaths, Australia, 2006, cat. no. 3302.0. Implications for Tasmania’s health care system The older age of the population and the poorer health status of the community place relatively higher demands on Tasmania’s health care system compared with those in other states and territories.

As well as ensuring that there are adequate acute hospital services in Tasmania, there needs to be an increased emphasis on prevention, early intervention and self-management of chronic disease, rehabilitation, coordination of care for people with chronic ill-health and the provision of care in community settings.

Clinical Services Plan: Update 21 Tasmania’s public acute hospital system

Introduction Tasmania has three major state-owned and -operated public acute hospitals – the RHH, the LGH and the NWRH (Burnie). The location of these hospitals, and the location of the Mersey Community Hospital, are shown in Figure 4. Together, they make up Tasmania’s public acute hospital system.

Figure 4: Location of hospitals by statistical local area

NWRH Burnie Circular Mersey Head Community Dorset Hospital Launceston Waratah/ Kentish General Break Meander Hospital O’Day Wynyard Valley Northern Midlands West Coast Central Highlands Southern Midlands

Royal Derwent Valley Hobart Hospital

Huon Valley

The Royal Hobart Hospital The RHH is a major teaching and research hospital with linkages to the University of Tasmania. It is the principal referral hospital for Tasmania and provides services primarily at role delineation4 levels 5 and 6 in medicine, surgery, critical care, aged care, rehabilitation, mental health, obstetrics and paediatrics. It provides the majority of statewide services including cardiothoracic surgery, neurosurgery, high risk obstetric care, neonatal and paediatric intensive care, hyperbaric medicine, complex paediatric surgery, gynaecological oncology and complex burns management. The RHH operates from a base of 540 beds including 437 overnight beds and 103 day beds. The RHH also has a contract with the private sector for the provision of public ophthalmology services and a partnership with the Hobart Private Hospital for some patient care and support services.

4 Role delineation is a process that designates levels of services and capacity to ensure that clinical services are provided safely and have appropriate support services, staffing, safety standards and other requirements. Role delineation levels range from 1 to 6, with level 1 services being the most simple and level 6 being the most complex.

22 Clinical Services Plan: Update The Launceston General Hospital The LGH is a significant teaching and research hospital with linkages to the University of Tasmania. It is the major referral hospital for the residents of the North and North West of Tasmania and provides services primarily at role delineation levels 4 and 5 in medicine, surgery, critical care, aged care, rehabilitation, mental health, obstetrics and paediatrics. It is Tasmania’s only provider of brachytherapy.5 The LGH operates from a base of 342 beds including 296 overnight beds and 46 day beds. The LGH also has contracts with the private sector for the provision of public patient services, including ophthalmology and nuclear medicine services. The North West Regional Hospital (Burnie) and the Mersey Community Hospital The NWRH (Burnie) is the regional public acute hospital for residents of the North West. It provides services primarily at role delineation levels 3 and 4 in medicine, surgery, critical care, obstetrics, paediatrics, mental health, drug and alcohol, and aged care and rehabilitation. It is a teaching and research hospital with linkages to the University of Tasmania. The Rural Clinical School of the University of Tasmania is located at the NWRH (Burnie). The NWRH (Burnie) operates from a base of 179 beds including 146 overnight beds and 33 day beds. The NWRH (Burnie) also has contracts with the private sector for the provision of public patient services including maternity, ophthalmology and diagnostic pathology and imaging services. Until November 2007, the NWRH operated under a ‘one hospital two campuses’ model, with the Burnie campus and the Mersey campus at Latrobe (approximately 60 km apart) operating under a single management structure. The 2007 Clinical Services Plan notes that continuing efforts to duplicate services across both campuses had created major sustainability problems and had compromised the quality of health care for the entire community. A change in role for both campuses was planned, with each campus complementing the other, allowing the NWRH in conjunction with primary health services to provide a comprehensive service to the entire community. It was proposed that high acuity intensive care, medical, surgical and emergency services would be consolidated on the Burnie campus and the Mersey campus at Latrobe would refocus on high-volume medical and surgical day-only services including chemotherapy, renal dialysis, booked surgery with admissions of up to 23 hours’ duration, low risk maternity and paediatrics, specialist aged care and rehabilitation and a full range of non- inpatient consulting services. A 24-hour emergency service was to be provided at both campuses with the Mersey retaining the capacity to resuscitate and support patients prior to transfer if required. Enhancement of ambulance and paramedic support also was proposed. On 1 August 2007, the then Australian Prime Minister announced that the Australian Government would guarantee the continued funding of a wide range of inpatient and outpatient services at the Mersey campus and support its re-establishment as the Mersey Community Hospital, managed by a community controlled and federally funded trust. The Australian Government’s intention was that the hospital would continue to provide a full range of services to the local community. On 20 August 2007, the Tasmanian Government agreed to sell the hospital to the Australian Government for a nominal $1.00, subject to a number of conditions. On 24 September 2007, the Australian and Tasmanian Governments signed a binding agreement to transfer ownership of the Mersey campus of the NWRH to the Australian Government. On 25 September 2007 the then federal opposition committed to honour the agreement if it were elected to government, and to work with the Latrobe and Devonport communities to implement it.

5 Brachytherapy is a type of radiation therapy in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumour – see the National Cancer Institute definition at .

Clinical Services Plan: Update 23 On 23 November 2007, the Australian Government assumed control of the Mersey Community Hospital. The 2007 federal election was held on 24 November. Consistent with the commitment it had made when in opposition, the new Australian Government reaffirmed its intention to ensure the provision of a full range of services to the local community, as long as services could be provided safely and to an acceptable level of quality. In January 2008 the Australian Government announced a further independent review of the feasibility and safety of retaining an intensive care unit at the Mersey Community Hospital. The review concluded that a high dependency unit is the most suitable model for the Mersey Community Hospital for the present and foreseeable future. On 7 March 2008 the Australian Government announced that it was seeking a religious and charitable or private sector organisation experienced in managing public hospitals to operate the Mersey Community Hospital as a public hospital from 1 July 2008. Tasmania’s public acute hospital system now consists, therefore, of three public hospitals which are owned and operated by the State (the LGH, the NWRH (Burnie) and the RHH) and one public hospital which is owned by the Australian Government and will be operated by a religious and charitable or private sector organisation from 1 July 2008. Together, these hospitals will be responsible for providing high quality, accessible and sustainable public acute hospital services to the entire Tasmanian community. The Tasmanian Government believes that the 2007 Clinical Services Plan provides the most appropriate framework for delivery of public acute hospital services to the residents of the North West and that the decision to provide a full range of services from the Mersey Community Hospital is likely to diminish service sustainability and reduce opportunities for service development which would have benefited all residents of the region. Nevertheless, the Tasmanian Government acknowledges the Australian Government’s intention to support the Mersey Community Hospital to provide a full range of services, and confirms its intention to ensure that the NWRH (Burnie) works collaboratively with the Mersey Community Hospital to provide the most comprehensive and integrated public acute hospital services for the region that are achievable in the circumstances. Table 11 summarises Tasmania’s public acute hospital facilities as at February 2008.

Table 11: Facility profiles – major hospitals Tasmania

RHH LGH NWRH (Burnie) MCH Facilities Capacity In use Capacity In use Capacity In use Capacity In use March March March March 08 08 08 08 Overnight beds Medical 94 88 114 106 34 30 34 24 Surgical 103 102 64 60 54 36 38 20 Total medical, surgical 197 190 178 166 88 66 72 44 Critical care beds Intensive care 9 9 6 6 8 4 Coronary care 3 3 5 5 4 Cardiothoracic ICU 3 3 High dependency 8 8 4 4 Total critical care 23 23 11 11 8 8 4 4 TOTAL MEDICAL, 220 213 189 177 96 74 76 48 SURGICAL AND CRITICAL CARE

24 Clinical Services Plan: Update RHH LGH NWRH (Burnie) MCH Facilities Capacity In use Capacity In use Capacity In use Capacity In use March March March March 08 08 08 08 Rehab and elder care IP rehab and elder care 23 23 18 18 12 8 NHP care (Strathcare) 8 0 Karingal 24 24 Transitional care unit 22 22 Geriatric evaluation unit 20 20 0 0 TOTAL REHAB 97 89 18 18 12 8 0 0 AND ELDER CARE Mental health Psychiatric ICU 8 Psychiatric medicine 34 20 20 24 24 TOTAL MENTAL 42 0 20 20 24 24 0 0 HEALTH Women’s and children’s Maternity 18 18 26 26 15 15 Gynaecology 11 5 NICU and SCN 16 16 9 9 Paediatrics 25 25 26 20 14 14 6 4 Birthing suites 8 8 8 8 4 4 TOTAL WOMEN’S 78 72 69 63 14 14 25 23 AND CHILDREN’S TOTAL OVERNIGHT 437 374 296 278 146 120 101 71 Day beds Oncology day 18 18 12 12 9 9 6 6 treatment Oncology day beds 2 2 2 2 1 1 1 1 Ambulatory 24 24 care centre Renal dialysis 20 20 15 15 unit offsite Renal dialysis onsite 5 5 12 12 Emergency 1 1 3 3 department beds Dental 1 1 Day surgery unit 12 12 20 20 8 8 10 10 Perioperative unit 9 9 Hyperbaric unit 2 2 Prenatal 3 3 assessment centre Paediatric 6 6 assessment unit Radiology 1 1 Specialist clinics 1 1 TOTAL DAY 103 103 46 46 33 33 20 20 TOTAL BEDS 540 477 342 324 179 153 121 91

Clinical Services Plan: Update 25 RHH LGH NWRH (Burnie) MCH Facilities Capacity In use Capacity In use Capacity In use Capacity In use March March March March 08 08 08 08 Other facilities Recovery 13 13 6 6 8 6 4 4 Linac 3 2 2 2 bunkers linacs Cath lab/procedural 1 1 1 1 imaging room Theatres 7 7 7 4 4 3 2 2 Procedure rooms 2 2 2 2 1 Emergency department ED resuscitation bay 4 4 2 2 2 2 1 1 ED treatment bay 31 31 14 14 10 8 4 4 ED consultation rooms 4 4 3 3 ED safe/seclusion rooms 2 2 Short stay unit 10 5 TOTAL ED SPACES 47 42 20 20 12 10 8 8 Imaging equipment MRI, CT, US, Nuc CT, US, Nuc CT, US, Nuc Med, CT, US, Med, vascular lab Med, vascular/ angiography general screening interventional and image laboratory, intensification screening procedure room Comments Planned PET in MRI to be installed Planned MRI in 2008 July 2008 2008

Notes: Numbers exclude delivery rooms and ‘beds’ for qualified newborns. Consulting and ambulatory facilities rooms are not documented in this table. NWRH (Burnie) paediatric unit has 10 beds + 4 cots. RHH dialysis has 18 chairs + 2 training chairs. Dialysis for Burnie residents is provided by LGH at the Parkside site in Burnie. Maternity and neonatal services for Burnie residents are provided by North West Private Hospital under a public contract. Three NWRH (Burnie) emergency department consulting rooms are used for outpatient visits during the day. Some inpatient wards in the NWRH (Burnie) currently are used for non-acute activities. When these are required for inpatient use, alternative accommodation will need to be provided for those occupying the space.

26 Clinical Services Plan: Update Principles for Tasmania’s health services

In endorsing Tasmania’s Health Plan, the State Government adopted the following key principles for Tasmania’s health services:

Tasmania’s health services will be: • accessible as close as possible to where people live, if services can be delivered safely, effectively and at acceptable cost; • appropriate to community needs; • client and family-focused; • integrated through effective service coordination and partnerships between providers; and • designed for sustainability. Where services cannot be delivered safely, effectively and at acceptable cost locally, access will be facilitated through service coordination, transport assistance and other appropriate support.

The Department has adopted the following definitions to support these principles: Accessible – ensuring care is available when (at the time) and where (in the location) people need it Safe – minimising risks, so that patients are safe from unintended harm Effective – providing care that results in a good outcome Efficient – using available health care resources wisely Appropriate – providing the ‘right’ care at the ‘right’ time, including health promotion and integrated community-based and hospital-based services Patient and family-focused – designed to meet the needs of patients and their families/carers, respectful of patients as individuals and enabling them to access information and be engaged as active participants in their own care

Consistent with the 2007 Clinical Services Plan, this update has a particular focus on sustainability, which requires public acute hospital services to: • have sufficient patient volume to support and maintain the competence of health care professionals; • support a staffing infrastructure that can withstand temporary shortages without excessive cost or operational burden; • have quality equipment and facilities, and appropriate access to necessary clinical and non-clinical support services; • have costs that are reasonable and manageable over time, in the context of competing demands for limited resources; and • have transparent and predictable funding allocations.

Implementation commitment 2 The Tasmanian Government re-endorses its commitment to the principles defined in the 2007 Clinical Services Plan and in particular to: • service accessibility where services can be delivered safely, effectively and efficiently; and • designing Tasmania’s public health services to ensure their sustainability.

Clinical Services Plan: Update 27 Progress since publication of the Clinical Services Plan

Inpatient activity Tasmania’s public acute hospital system has continued to provide a high level of service to the community (Table 12).

Table 12: Admissions to Tasmanian public acute hospitals

Hospital 2004–2005 2005–2006 2006–2007 Diff % change 2000–01 % change 2004–2007 2004–2007 2000–2007 RHH 53,618 54,623 54,881 1,263 2% 43,263 27% LGH 33,403 35,310 35,399 1,996 6% 23,930 48% NWRH 11,808 12,346 11,951 143 1% 11, 58 0 3% (Burnie) NWRH 3,934* 7,735 7,134 (Mersey) Interstate 1,359 1,813 2,267 908 67% public Other 6,275 6,063 8,978 2,703 43% Grand 110, 397 117,889 120,610 7,013 6% Total

Notes: *NWRH (Mersey) submitted data for only part of 2004–05, from 1 December 2004 to 30 June 2005. Renal dialysis separations in Burnie are included in the NWRH (Burnie) separations. There were 3,618 such separations in 2006–07.

Table 12 shows that there was modest growth in inpatient activity at the RHH and the LGH and a small reduction in activity at the Burnie and Mersey campuses of the NWRH in the year to June 2007. Overall, the rate of growth in admissions slowed over the three-year period to June 2007 compared with the previous four-year period. There was considerably more growth in admissions in the North (48%) than the South (27%) over the period 2000–2007 while there was very little growth in admissions to the NWRH (Burnie) over that period.

Emergency activity Over the past three years, emergency department presentations across Tasmania have increased by 6 per cent. There has been significant growth in emergency activity at the NWRH (Burnie) and the LGH (Table 13).

Table 13: Emergency department presentations

Hospital 2004–05 2005–06 2006–07 Diff % Change % of total (2006–07) NWRH (Burnie) 22,054 23,155 24,438 2,384 11% 20% NWRH (Mersey) 12,462* 22,044 21,753 18% LGH 30,941 32,050 34,409 3,468 11% 29% RHH 37,922 39,277 39,062 1,140 3% 33% Total 103,379 116, 526 119,662 6,992 6% 100%

Note: *NWRH (Mersey) submitted data for only part of 2004–05, from 1 December 2004 to 30 June 2005.

28 Clinical Services Plan: Update Community-based services There has been continued improvement in a number of indicators relating to community-based services. These indicators are published in Your Health and Human Services: Progress Chart and include an increase of more than 37.5 per cent in occasions of service for adult dental care.

Clinical Services Plan initiatives A number of the initiatives identified in the Clinical Services Plan have been progressed (Table 14). Because of the change of ownership of and operational responsibility for the Mersey Community Hospital, initiatives relating to the Mersey Community Hospital and the NWRH (Burnie) are not included in this table but are addressed separately in this report.

Table 14: Progress in implementing Clinical Services Plan initiatives

Health system initiatives Progress New infrastructure Redevelop the RHH The Hobart Railyards has been confirmed as a suitable site for a hospital development. A draft service plan has been developed and development of master plans, a feasibility study and an investment evaluation are progressing. This information will underpin the development of a business case which will be completed by the end of 2008. Develop new ICCs at Hobart The Australian Government has committed $15 million towards the (within or adjacent to the RHH) establishment of an ICC, including a renal dialysis unit, in Launceston. and Launceston (close to the The Department will initiate planning with the Australian Government LGH); on Hobart’s eastern Department of Health and Ageing, as a priority, to progress the shore; and in the Kingborough implementation of this initiative. areas; and enhance existing services at a range of sites An ICC is being planned as a component of the new RHH. It will be collocated with the RHH and will focus on the delivery of both acute and complex chronic health services to an ambulatory client group that may need access to tertiary hospital backup and support. The focus will be on day-only episodes of care. The ICC service will have three key functions: • be the portal for elective, non-urgent day surgery and other procedures; • deliver a wide range of ambulatory care services, including diagnostic services; and • provide specific services for people with chronic and complex co-morbid conditions, including cancer, diabetes/renal, cardio- respiratory and gastroenterology. Undertake a feasibility study to The Australian Government has committed up to $7.7 million towards assess the appropriate location the establishment of an additional radiation oncology unit in the North for a 5th linear accelerator or North West. The new radiation oncology service will be located at either the NWRH (Burnie) or the LGH. Adopt a planned and coordinated The Australian Government has approved Medicare eligibility for two approach to medical imaging magnetic resonance imaging units – one in North West Tasmania and infrastructure development one at the LGH. Purchase of the LGH unit has been approved. New models of care Develop new models of care Detailed planning has commenced for the redevelopment of the for emergency departments – RHH. New models of care are being planned, including an emergency short stay/medical assessment short stay unit and a fast-track clinic (already in the new emergency units, fast track units, psychiatric department of the existing RHH) together with an emergency mental emergency care centre, health zone and medical assessment and planning units. collocated GP clinics Planning for the redevelopment of the LGH emergency department also has commenced, including planning for new models of care consistent with this recommendation. Service enhancement Review the business case for The Australian Government has committed $3.5 million in support of introduction of a PET/CT a PET scanner at the RHH. scanner to the RHH and consider introducing the service

Clinical Services Plan: Update 29 Health system initiatives Progress Service reviews/redesign Review adult medical Adult medical retrieval services have been reviewed with the retrieval services assistance of an independent advisor. An implementation plan for a sustainable service is being developed. Review patient transport and The Department currently is undertaking a comprehensive review accommodation services of all health transport services, including ambulance services, medical retrieval and patient transport arrangements, as well as patient accommodation arrangements. The review is expected to be completed by mid-2008 and its findings will be factored into development of transport and retrieval services and accommodation arrangements across the State. The Department will complete a transport strategy which will address issues such as integration of modes of transport and will complement Tasmania’s Health Plan such that improved transport options are harmonised with the development of new models of care for health services. The Australian Government has committed $10 million for patient transport services including the purchase of community buses. The Department also will complete a strategy for patient accommodation services. Maintain the RHH as the An independent review has been completed and has confirmed the statewide provider of autologous recommendation of the Clinical Services Plan, which is now being bone marrow transplantation, implemented. Clinicians from Launceston will be engaged in subject to independent review a statewide service to be based at the RHH. Relocate vascular surgery from The major vascular surgery service previously provided at the NWRH the NWRH (Mersey) to the LGH (Mersey) has ceased. A statewide vascular service is now provided from the RHH with outreach to the LGH. Clinical leadership and engagement Establish clinical networks in A clinical leader has been appointed to the cancer clinical network a range of clinical areas and a and establishment of the network is progressing. An interim Clinical Clinical Advisory Council Advisory Council has been convened.

Aligning the Department’s structure with service delivery objectives During consultation for the development of the 2007 Clinical Services Plan, many stakeholders suggested that the allocation of responsibility for acute and primary health care to separate divisions of the Department was a major barrier to integrating care at an operational level.

In March 2008 the Minister and the Secretary of the Department announced a reorganisation of the Department to increase its focus on patients and clients and better reflect priorities under Tasmania’s Health Plan. Key features of the reorganisation include: • bringing together acute hospital and primary health functions; • delegating greater autonomy to the major hospitals within a clearly defined accountability structure; • reorganising resources to establish a Statewide Systems Development Team, focusing on the implementation of Tasmania’s Health Plan, development of ICCs and GP Superclinics, consumer engagement and university partnership; • creating a new approach to mental health by bringing together Statewide Specialist Services and Mental Health Services; • appointing a Director of Community Sector Development to work with the non-government sector, recognising its large and growing role in service delivery (currently around 10% of the Department’s budget); • elevating the importance of clinical and professional advice, with the Director of Public Health and Chief Nursing Advisor both reporting directly to the Secretary; • creating a new Health and Wellbeing Operational Unit incorporating Oral Health and key service delivery elements in Population Health;

30 Clinical Services Plan: Update • developing a new senior Care Reform role to focus on improvements in safety and quality, workforce strategy and development, change management, and public engagement; • elevating the role of Chief Finance Officer to report directly to the Secretary, reflecting the critical issue of effective budget management and improved financial strategy; • new roles of Financial Director, initially in the RHH and the LGH, with responsibility to ensure effective financial management; • moving supporting business services such as human resources and information technology into a client-focused operational unit with oversight from service areas; and • opening an office in Launceston to assist in responding to community needs in the North and North West.

The Department has created an Aged, Rehabilitation and Palliative Care Directorate to enhance leadership and focus for rehabilitation, aged care and palliative care across the State.

Implementation commitment 3 The Department will: • complete the business case for the redevelopment of the RHH (including an ICC) by December 2008; • work with the Australian Government to: – progress planning for an ICC (including a renal dialysis service) in Launceston and a radiation oncology unit in Burnie or Launceston; and – progress the installation of MRIs at the LGH and in Burnie, and a PET scanner at the RHH as a priority; • complete the redevelopment of the LGH emergency department by June 2010; • publish an implementation plan for a sustainable medical retrieval service by June 2008; • complete a transport strategy by June 2008 to enable the development of a comprehensive, coordinated service that is client-focused and timely and provides clinically appropriate transport options; • complete a patient accommodation strategy by June 2008; and • by December 2008 finalise implementation of statewide services for bone marrow transplantation and vascular surgery, including identifying a specific statewide services budget and facilitating agreement about the extent of outreach services and the role of LGH clinicians.

Clinical Services Plan: Update 31 The service capability framework

Principles Some health services depend for their viability on a critical mass of professionals and/or patients, costly infrastructure and/or scarce support services. Many complex services cannot be established in isolation from other complex services. In most health care systems, this results in ‘clustering’ of complex services within a small number of institutions. Not all hospitals can provide all services to all patients and it is not in the interests of the community for them to attempt to do so.

With a population of less than 500,000 people, there are several services which can be provided safely, efficiently and effectively in Tasmania only if they are provided from one or two main sites in the State.

The 2007 Clinical Services Plan presents a service capability framework for acute hospital services based on local, regional referral and statewide service designations. The planning principles reiterated earlier in this report, together with the service capability framework, can be applied to all service development proposals to ensure that rational decisions about the configuration of health services are made for the benefit of the entire community.

Implementation commitment 4 The Department endorses and clarifies the following principles for regional referral and statewide services: • a patient-focused, system-wide approach will be taken, based on the needs of all Tasmanians. Services will not be designed or developed around the needs of individual clinicians, individual regions or individual hospitals; • critical clinical inter-dependencies will be taken into account when planning the location of regional and statewide services; • funding to enable regional and statewide services to fulfil their additional responsibilities (e.g. to enable the provision of outreach services) will be provided as appropriate, through funding streams independent of normal hospital budgets; • regional and statewide services will be required to participate in the usual clinical and management quality and accountability processes that apply at their host hospital; • regional and statewide services that are provided with additional infrastructure funding to support an outreach role will be required to account for their performance to their broader communities of interest, addressing issues such as accessibility and outcomes of care across the State; • most statewide services will continue to be located at the RHH, because it has the highest level of infrastructure, necessary associated services and access to important non-health organisations that aid in quality service provision and attraction and retention of professional staff for those types of services; and • if a statewide service does not depend on critical internal or external relationships that are more achievable at the RHH, the service may be located at the LGH.

32 Clinical Services Plan: Update Cooperative service development and support Competition between Tasmania’s public acute hospitals has the potential to lead to harmful duplication and to diminish the quality of services for all Tasmanians. Competition needs to be replaced by cooperation and all of Tasmania’s public acute hospitals need to work within the service capability framework to ensure that services are developed in a planned and rational way.

To ensure transparency and to foster collaboration, the chief executive officers of each of the NWRH (Burnie), the LGH and the RHH will be required to submit all service development (including senior staff recruitment) proposals to the Department, which will consult with all public acute hospital chief executive officers. Proposals will not be approved if they: • jeopardise the sustainability of existing services; • undermine the planned development of services in other regions (particularly the North and/or North West); and/or • may lead to inappropriate pressure in the future for the development of complex services where these are likely to be unsustainable.

Flexibility will be required, of course, to ensure that clinicians who are interested in working in Tasmania are not discouraged because their residential and/or professional preferences are inconsistent with the Clinical Services Plan. Innovative arrangements to ensure appropriate service access may be necessary if it is not possible to recruit clinicians to specific locations within the State. The key point is that each of the public acute hospitals must work together, supported by the Department, to take a ‘whole-of-state’ approach to service development, and recognise that service development initiatives in one hospital may have an unintended negative effect on another part of Tasmania’s health care system.

Implementation commitment 5 The Department will implement mandatory policies and procedures regarding the introduction of new services and technologies to Tasmania’s public acute hospitals. These policies and procedures also will cover the recruitment, credentialling, and scope of clinical practice of senior clinical staff. The objective will be to ensure that recruitment and service development initiatives of individual hospitals do not jeopardise the sustainability of existing services; do not undermine the planned development of services in other regions; and are not likely to lead to inappropriate pressure in the future for the development of complex services where these are likely to be unsustainable.

Statewide services – governance, funding and accountability When service quality and/or sustainability requires concentration of services, funding will be provided to enable outreach services to other parts of the State, if it is possible to provide these on a sustainable basis.

Outreach services may be provided to the North West region from either the RHH or the LGH, but in the longer term the development of a strong regional referral relationship between the NWRH (Burnie) and the LGH will be in the overall community interest.

Implementation commitment 6 The Department will ensure that, where feasible: • arrangements for outreach services are made between hospitals rather than clinical units or individual clinicians; and • the LGH assumes a more formal and comprehensive regional support role to the North West region. Services which are viable only on an outreach basis in the North West region will be provided by arrangement with the LGH where possible, rather than with individual clinicians or the RHH.

Clinical Services Plan: Update 33 Accountability for the delivery of outreach services is a critical feature of the capability framework and will be promoted and enforced by the Department. The Department will enter into formal service agreements with the relevant hospital in relation to each service for which funding is provided to enable outreach services. These service agreements will define transparent accountability arrangements, engaging stakeholders from across the State as appropriate.

While most people choose to access health services close to where they live, for various reasons relating to their personal circumstances and/or service availability some eligible patients may elect to access services in areas remote from their place of residence. This is particularly the case for services which are not offered in all geographic regions. The Australian Health Care Agreement between Tasmania and the Australian Government obliges all public hospitals to offer their services (including regional and statewide services) to all eligible patients equitably on the basis of clinical need (rather than the patient’s place of residence). The Department will remind all hospitals of this requirement.

Regional and statewide services that are required to deliver services from multiple sites (through either outreach or dual-site arrangements) will be funded to enable them to develop those arrangements across the State on a sustainable basis and to implement appropriate arrangements to demonstrate their accountability to clinicians and consumers.

The capability framework is described in Table 15 below and its application to existing services is described in Table 16 below.

Supporting local clinicians in their delivery of specialist services is a key responsibility for regional and statewide services. In most circumstances, a collaborative arrangement between regional/ statewide services and local clinicians will provide the best patient care – for example, patients with cystic fibrosis not only benefit from highly specialised care provided on an outreach basis, but also depend on the care provided by local teams which include GPs, nurses, community allied health practitioners and general physicians. Cancer patients also may receive a combination of specialist care in a statewide unit, specialist care provided on an outreach basis and generalist care provided by GPs, nurses, allied health professionals and general physicians and surgeons closer to where they live. In some circumstances formal shared care arrangements may be appropriate, but in other circumstances informal liaison and support arrangements will apply.

Implementation commitment 7 The Department will develop and implement, by July 2010, standard governance, funding and accountability agreements for regional and statewide services, commencing with the following services: • adult and paediatric cystic fibrosis; • bone marrow transplantation; • cancer services (LGH to NWRH); • specialist cardiology (LGH to NWRH); • infectious diseases; • neonatal intensive care, paediatric intensive care, neonatal and paediatric retrieval; • renal medicine (LGH to NWRH); and • vascular surgery.

The allocation to a hospital of funding for outreach services will carry with it responsibility to ensure the quality and reliability of those services and to demonstrate accountability for service accessibility and quality to providers and consumers from the outreach areas. The performance management framework for each hospital chief executive officer will incorporate accountability for ensuring that statewide service responsibilities are fulfilled.

34 Clinical Services Plan: Update Statewide service, dual site Both and LGH RHH Funded to provide services at both and LGH RHH. May also be funded to provide services via outreach to patients from the North West. Generally outreach to the North West would be from LGH High May require expensive technology (but not very high cost) and/or collocated specialist support services May have a demonstrated volume/quality relationship which justifiesconcentration servicesof on 2 sites Sufficient to support at least 3 practitioners at each LGH of and RHH if frequent out-of- hours recall Responsibility the of designated of point single – hostsite management control for the State (either or LGH RHH) Led the by management site with engagement and of accountability to all regions Single Tasmanian service, may be networked interstate or part a broader of Tasmanian clinical network Statewide service, single site with outreach Either LGH or RHH, providing RHH,providing or LGH Either services locallyoutreach andvia to patients from all regions Funded to provide sustainable services to one or more regions on an outreach basis High May require very high cost technology and/or collocated specialist support services May have a demonstrated volume/quality relationship which justifiesconcentration servicesof on 1 site Sufficient to support at least 3 practitioners at single site if frequent out-of-hours recall, and to support sustainable outreach services Responsibility the of host site (LGH or RHH) Led the by host site (LGH or RHH) with engagement and of regions accountabilityall to Single Tasmanian service, may be networked interstate or part a broader of Tasmanian clinical network Statewide service, single site Either LGH or RHH, or providing EitherLGH patientsservices whoto locally attend from all regions Not obliged/expected Not to provide outreach in community inpatientsettings or although arrangements local apply may agreementby High May require very high cost technology and/or collocated specialist support services May have a demonstrated volume/quality relationship which justifiesconcentration servicesof on 1 site Sufficient to support at least 3 practitioners at single site if frequent out-of- hours recall, unless special apply arrangements Responsibility the of host site (LGH or RHH) Accountable to the host site (LGH or RHH) Single Tasmanian service, may be networked interstate or part a broader of Tasmanian clinical network Regional acute hospital referral service LGH, providing services to patients from the North West May be funded to provide outreach in community or inpatient settings in the North West Medium May require expensive technology (but not very high cost) and/or collocated specialist support services May have a demonstrated volume/quality relationship which justifiesconcentration servicesof on 2 sites Sufficient to support at least 3 practitioners at each LGH of and RHH if frequent out-of- hours recall Responsibility the of host site (LGH and RHH) Led the by host sites (LGH and RHH) with LGH ensuring engagement and of accountability to NWRH May be a specific clinical network incorporating each site (LGH and RHH) or part a broaderof Tasmanian clinical network Local acute hospital service LGH, NWRH and RHH If unable to recruit locally, may be supported on an outreach basis from another site As above, and also may provide outreach in community settings or to Mersey Community Hospital via service level agreements Low Not dependent on high cost technology or other highly services specialised No apparent volume/quality relationship or sufficient volume at each site to meet standards Sufficient to support at least 3 practitioners at each host site if frequent out-of-hours recall Responsibility the of host site (NWRH, and LGH RHH) Accountable to the host site (NWRH, and LGH RHH) May be a specific clinical network incorporating each site (NWRH, LGH, RHH) or part a broader of Tasmanian clinical network Characteristic Service base Outreach Complexity Infrastructure and support requirements Volume/quality relationship Throughput Management Accountability for service accessibility and quality (clinical governance) Networking arrangements Table 15: Service 15: Table capability framework

Clinical Services Plan: Update 35 Australian Government funding is available for a 5th linear accelerator in the North or the North West. The service will be provided the by LGH The is LGH the sole provider of brachytherapy for the State The RHH is the statewide provider autologousof BMT. The LGH provides stem cell harvesting only, and transfers stem cells to the RHH for cryopreservation and transfusion Service scope to be reviewed The is LGH the service provider with staffing support also provided theby RHH The RHH is the service provider and provides outreach clinics in the North and North West Service characteristics Service Participants in cancer network. Sub-specialists (radiation oncology, medical oncology, haematology) from both services need to work collaboratively Participants in the cancer network Participants in the cancer network. RHH and LGH haematologists to work together to ensure common approach to BMT. Should network with interstate specialty services Participants in the adult surgical services network Participants in the emergency, critical care and trauma servicesnetwork Should network with interstate specialty services Requirement to participate in a clinical network RHH serviceLGH has dual accountability to LGH and NWRH LGH RHH and LGH RHH Whole state of Whole state of Clinical governance accountability LGH andLGH RHH LGH RHH (statewide director) RHH LGH (statewideLGH director) RHH (statewide director) Managed by Yes – for outreachYes services provided by toLGH NWRH No Yes No Yes Yes Requirement for specific funding for outreach and/ or statewide accountability arrangements Regional referral Regional Statewide, single site Statewide, single site for transplantation, dual site for harvesting Statewide, single site Statewide, single site with outreach Statewide, single site with outreach Service type Cancer services (medical oncology, malignant haematology and radiation oncology) Brachytherapy Bone marrow transplantation Bariatric surgery Adult medical retrieval service Adult and paediatric cystic fibrosis Service Applying the service capability framework to existing services the serviceApplying framework capability 16: ApplicationTable of service capability framework to existing services

36 Clinical Services Plan: Update The surgeons LGH have developed a special interest in this service. Continued concentration this of specialist service on one site is appropriate The RHH is the only provider of complex obstetric and level 3 NICU services Service scope to be reviewed The RHH is the sole provider of cardiothoracic surgical services for the State There are two interventional cardiology services in the public sector – at the and LGH the RHH. There is no electrophysiology service in Tasmania Consider introduction cardiac of electrophysiology as part a of tertiary centre for the delivery of the full range cardiac of services according to interventional cardiology inpatient demand Service characteristics Service Participants in the adult surgical services network Participants in the women’s and children’s network Participants in the adult surgical services network Participants in the cardiac network. May benefit from participation in interstate outcome databases Participants in the cardiac network. May benefit from participation in interstate outcome databases Participants in the cardiac network. May benefit from participation in interstate outcome databases Requirement to participate in a clinical network LGH Whole state of RHH RHH RHH serviceLGH has dual accountability to and LGH NWRH LGH orLGH RHH (host site) Clinical governance accountability LGH RHH RHH RHH LGH andLGH RHH LGH orLGH RHH Managed by

No, unless dual site or outreach arrangements developed are No No, unless dual site or outreach arrangements developed are No, unless outreach arrangements are developed Yes – for outreachYes services provided by toLGH NWRH No Requirement for specific funding for outreach and/ or statewide accountability arrangements Statewide, single site Statewide, single site Statewide, single site Statewide, single site Regional referral Regional To be developedTo as a statewide, single site service Service type Complex upper gastrointestinal surgery including pancreatic, major oesophageal and hepatobiliary surgery Complex materno-Complex foetal medicine Complex ENT head and neck surgery Cardiothoracic surgery Specialist cardiology including interventional Cardiac electrophysiology Service

Clinical Services Plan: Update 37 Development to a statewide service on dual sites or a regional acute hospital referral service should be considered Demand and opportunities and Demand for integration with other specialties to be reviewed Currently providing outreach services but sustainability is not clear with single practitioner service. Review scope service of to determine whether second practitioner can be recruited and service sustainability improved The Tasmanian Clinical Genetics Service (TCGS) is the statewide provider clinical of genetics services. providesTCGS genetics outreach services to the North and North West with contractual arrangements with Genetics Health Services Victoria for visiting clinical geneticists and genetic testing. Genetics Health Services Victoria conducts testing of new born babies on a contract basis. TheTasmanian Government assumed responsibility for the Tasmanian Familial Bowel Cancer Registry in January 2008 Service characteristics Service Participants in the adult medical services network Participants in the adult medical services network Participants in the women’s and children’s network The will TCGS participate in a number networks of as relevant (e.g. cancer network, adult medical services network) Pathology network (if established) Requirement to participate in a clinical network RHH and LGH RHH RHH DHHS DHHS Clinical governance accountability RHH (statewide director) RHH RHH Hosted RHH, by managed the by Tasmanian Clinical Service Genetics Hosted RHH, by managed by Statewide Forensic Pathology Service Managed by Yes No No, unless outreach are arrangements formalised Yes Yes Requirement for specific funding for outreach and/ or statewide accountability arrangements Statewide, single site with outreach Statewide, single site Statewide, single site Statewide, single site with outreach Statewide, single site Service type Infectious diseasesInfectious Hyperbaric medicine Gynaecological oncology Geneticsservices Forensic pathology Service

38 Clinical Services Plan: Update

Consider establishing a statewide service coordinated through a single structure administrative Currently providing outreach services but sustainability not clear with single practitioner service. Review scope of service to determine whether second practitioner can be recruited and service sustainability improved Services are all provided from the RHH and should not be duplicated in the State Consider establishing a statewide service coordinated through a single structure administrative Consolidate and formalise agreements with interstate hospitals to ensure ongoing cover Extensive burns cases are referred to to referred are cases Extensive burns Victoria for specialised treatment. andLGH NWRH manage minor burns Service characteristics Service Pathology network to be established if statewide service is not established Participants in the women’s and children’s network Participants in the women’s and children’s network Medical imaging network to be established if statewide service is not established Participants in the adult surgical services network Participants in the adult surgical services network Requirement to participate in a clinical network Local acute hospital (LGH,NWRH, RHH) moving to statewide accountability RHH Whole State of Local acute hospital (LGH, NWRH, RHH), moving to statewide accountability RHH RHH Clinical governance accountability Local acute hospital (LGH, NWRH, RHH) moving to statewidedirectorate RHH RHH Local acute hospital (LGH, NWRH, RHH), moving to statewidedirectorate RHH RHH Managed by Not at present, but would be required if statewide service developed is No, unless outreach are arrangements formalised No Not at present, but would be required if statewide service developed is No, unless outreach are arrangements developed No, unless outreach are arrangements developed Requirement for specific funding for outreach and/ or statewide accountability arrangements Local acute hospital service, moving to statewideservice Statewide, single site Statewide, single site Local acute hospital service, moving to statewideservice Statewide, single site Statewide, single site Service type Pathology services Paediatric surgery Neonatal intensive care/paediatric intensive care/ paediatric and neonatal retrieval Medical imaging Major neurosurgery Major Major burns Service

Clinical Services Plan: Update 39 Provided from Hobart to via LGH outreach arrangements. Should continue to be consolidated on one site and provided to the North and North West on an outreach basis To be developedTo as a statewide service in partnership with Drug and Alcohol Services and the Pharmaceutical Services Branch Renal medicine is provided from two nodes, one at the and LGH one at the RHH. The provides LGH a significant outreach service to patients who reside in the North region West Consider establishing a statewide service coordinated through a single structure administrative Australian Government funding confirmed Service characteristics Service Participants in adult surgical services network Participants in adult medical services network Participants in adult medical network, but clinicians from both services need to work collaboratively Pharmacy network to be established if statewide service is not established Participant in medical imaging network if developed Requirement to participate in a clinical network Whole State of but particular accountability to LGH Whole State of RHH serviceLGH has dual accountability to LGH and NWRH Local acute hospital (LGH, NWRH, RHH) RHH Clinical governance accountability RHH (statewide director) RHH (statewide director) LGH andLGH RHH Local acute hospital (LGH, NWRH, RHH) RHH Managed by Yes Yes Yes, for outreachYes, services provided by toLGH NWRH Not at present, but would be required if statewide service developed is No Requirement for specific funding for outreach and/ or statewide accountability arrangements Statewide, single site with outreach To be developedTo as a statewideservice Regional referral Local acute hospital service Statewide, single site Service type Vascular surgery Specialist pain management Renal medicine Pharmacy PET/CT scanning Service

40 Clinical Services Plan: Update Specific service issues

Autologous The 2007 Clinical Services Plan recommends that there should be a statewide service bone marrow with an appointed director and the development of protocols for early transfer back transplantation to Launceston for appropriate patients. An independent review has been conducted and has supported these recommendations, which are being implemented. Adult medical The LGH oversees the medical coordination and escort components of the retrieval retrieval service and a part-time director is appointed to manage the service. The service evolved on a voluntary ‘opt-in’ basis with critical care consultants, anaesthetists and registrars to provide support to the retrieval service. A statewide working party (comprising the Deputy Secretary, Acute Health Services and senior clinicians from each of the major hospitals and Tasmanian Ambulance Service) identified the need to strengthen the service to ensure its future sustainability, including taking into account the recommendations from Tasmania’s Health Plan. External advice was sought from Dr Peter Sharley, Royal Adelaide Hospital Mediflight Director 2002–07, to assist that process. Workforce shortages threatened the sustainability of the service in 2007. In order to maintain the service, locum medical staff were engaged on an interim basis pending a longer term solution to be identified by the Sharley Report. The Sharley Report is being considered by the Department and an implementation plan is being developed. Included in this approach will be the results of negotiations between the Australian Government and the Royal Flying Doctor Service for funding to enhance the retrieval service through employment of 2.5 full-time equivalent medical specialists and recurrent funding for training of medical and flight paramedic staff on aeromedical service provision.

Implementation commitment As noted in implementation commitment 3 (see page 31), the Department will publish an implementation plan for adult medical retrieval services by June 2008 and will finalise implementation of a statewide service for bone marrow transplantation by October 2008.

Bariatric surgery The 2007 Clinical Services Plan recommends that: • bariatric surgery should be conducted only at the RHH as a single site service; • surgeons should undergo specific credentialling and definition of scope of clinical practice; • only people who meet agreed criteria should be admitted to the program; • the number of people to be offered surgery each year should be determined by the Division of Surgery, taking into account demand; • waiting lists and other indicators of demand should be monitored; and • outcomes should be audited. In most developed health services, bariatric surgery is recommended as a treatment option for adults with morbid obesity if a number of health-related criteria are met. A significant relationship between volume of cases and outcomes has been demonstrated for bariatric surgery.6 The 2007 Clinical Services Plan recommendations are reiterated. In addition, there is an opportunity for the Tasmanian health care system to take a more integrated approach (incorporating a broader range of medical and surgical disciplines) to the increasing challenge of managing patients with morbid obesity.

6 Nguyen NT, Paya, M, Stevens CM, Mavandadi S, Zainabadi K, Wilson SE. The Relationship Between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers. Ann Surg. 2004 October; 240(4): 586–594. Clinical Services Plan: Update 41 Implementation commitment 8 The Department will oversee the development and implementation of a plan for the provision of bariatric surgery by the RHH by January 2009, and by December 2009 will develop an integrated statewide multidisciplinary strategy for the management of patients with morbid obesity.

Cardiac The 2007 Clinical Services Plan recommends that it is clinically appropriate for a single electrophysiology site electrophysiology service to be developed in Tasmania and that the service could be located at either the LGH or the RHH. The 2007 Clinical Services Plan recommendations are reiterated.

Implementation commitment 9 The Department will complete a feasibility study into cardiac electrophysiology services by June 2010.

Hyperbaric There is continuing debate about the facilities that should be developed at the RHH medicine to support Hyperbaric Oxygen Therapy (HBOT) for various conditions. A large number of reviews of this treatment have been conducted. Evidence of effectiveness is limited to defined clinical indications. The Medical Services Advisory Committee (MSAC) of the Australian Government has recommended continuation of public funding for a limited range of indications. It is recommended that: • the RHH service is designed for the management of patients suffering from conditions in which HBOT has been shown to be effective – in particular decompression illness, gas gangrene, air or gas embolism, diabetic wounds including diabetic gangrene and diabetic foot ulcers, necrotising soft tissue infections including necrotising fasciitis and Fournier’s gangrene and the prevention and treatment of oteoradionecrosis. In addition, in the absence of new evidence of lack of effectiveness, it would be reasonable to design the service to provide treatment of non-healing, refractory wounds in non-diabetic patients and refractory soft tissue radiation injuries; • the service is reviewed with a focus on ensuring that a sustainable service is available for patients suffering from conditions for which there is evidence of the effectiveness of the treatment. This may require consideration of workforce support arrangements with interstate units; and • if HBOT is to be provided for a broader range of clinical conditions it should be provided under research conditions, in clinical areas in which a need for further research has been identified. In these circumstances, consideration needs to be given to the research priority of this service and potential sources of funding to ensure that funding is not diverted from other areas of clinical priority.

Implementation commitment 10 The Department will complete an expert review of hyperbaric oxygen therapy by June 2009.

Medical imaging The 2007 Clinical Services Plan recommends consideration of statewide services for both pathology and medical imaging. Although these services are operating cooperatively across the State, it is considered that upcoming workforce challenges will Pathology require a single statewide management focus to ensure sustainable service delivery. The Clinical Services Plan recommendations are reiterated.

42 Clinical Services Plan: Update Implementation commitment 11 The Department will complete feasibility studies of statewide services in medical imaging and pathology by December 2009.

Rehabilitation A review of Tasmania’s rehabilitation services, which was completed in April 2007, confirmed that relative to national standards there is a current shortfall of 50–60 beds across the State, with the North and North West having the most significant need for resources. The review proposed a strategy containing nine elements: • formalise the establishment of a Tasmanian rehabilitation network to enhance the status of rehabilitation and provide statewide policy direction, service planning and training; • re-balance the investment in inpatient services by increasing provision for rehabilitation and other sub-acute care; • establish integrated rehabilitation programs and organisational structures within each region, linking acute care, sub-acute care and community rehabilitation programs; • promote an integrated, patient-focused model of service delivery that extends across settings and includes patient identification/referral, assessment, care planning, case management and discharge planning; • change current utilisation patterns to make more effective use of available rehabilitation resources and improve patient outcomes; • align rehabilitation service development and specialisation with relevant acute clinical service planning and delivery; • develop and implement a rehabilitation workforce strategy including: – leadership and team building; – recruitment/retention; – training; – making more efficient use of available resources; and – investment; • support the development of specialist rehabilitation programs in brain injury, spinal and amputee; and • address infrastructure deficiencies that restrict service capacity and effectiveness in facilities, equipment and transport.

The review proposed the following strategic investment priorities: • build a 32-bed inpatient unit in the North; • increase the number of allied health staff working in the LGH rehabilitation unit; • develop step-down facilities in the North, including a community rehabilitation service as well as Geriatric Evaluation and Management and transition care beds and transition care packages; • improve medical coverage in the North West, including access to consultation– liaison services provided from Launceston or Hobart; • develop step-down facilities in the North West including a community rehabilitation service as well as transition care beds and transition care packages. The location of such services at the Mersey Hospital should be considered as part of the Clinical Services Plan; and • workforce development. These recommendations are supported. In particular, there is a critical need for service development in the North and North West of the State and significant investment in community-based resources is required to prevent inappropriate hospitalisation.

Clinical Services Plan: Update 43 Implementation commitment 12 The Department will formalise the establishment of a rehabilitation and aged care network by August 2008 and publish an implementation plan for rehabilitation services by February 2009.

Vascular surgery The 2007 Clinical Services Plan recommends the following structure for vascular surgery: • designation as a statewide service, led from Hobart; • the existing surgeon in the North West to be offered the opportunity to move his practice to Launceston and be appointed to the LGH as a member of the statewide vascular surgical team; • the statewide vascular surgical team to provide back-up and support for the Launceston service through visiting consultancy services and on-call, professional and locum support; • outreach services to continue to be provided from Hobart and/or Launceston to the North West, by arrangement with the statewide service; and • all vascular surgeons, as a condition of their appointment, to participate in a statewide audit. After the 2007 Clinical Services Plan was published the Mersey Community Hospital’s major inpatient vascular surgical unit closed, but the surgeon did not relocate his practice to Launceston. Public acute hospital services currently are based in Hobart and the Hobart vascular surgeons provide an outreach service (consulting and low complexity operating) to Launceston. The Australian and New Zealand Society for Vascular Surgery considers that for a population catchment of 500,000 people there should be a unit of four surgeons and that a minimum of two or more surgeons is required in any one location to sustain a resident specialist service. Hospitals that perform high volumes of complex vascular surgical procedures have lower mortality rates than hospitals that perform low volumes.7 Mortality following a ruptured abdominal aortic aneurysm is high – the case fatality from rupture is 80 per cent, with most patients dying before admission or within 30 days of surgery. The outcome in women is worse than in men.8 A study which examined the resource use and outcomes of patients transferred from community centres to tertiary care centres following the diagnosis of ruptured abdominal aortic aneurysms found that the transferred group took a median of 7.2 hours to reach the operating room compared with 1.8 hours for the non-transferred group. The non-transferred group had a 41 per cent incidence of mortality within 24 hours of surgery compared with 10 per cent in the transferred group. The authors speculated that this difference might indicate that transferred patients were pre-selected with sufficient cardiac reserve to survive the initial transfer period. However, no data on the rate of death during transfer were available. The overall 30-day mortality rates were not statistically different between those transferred (65%) and those not transferred (69%), (p>0.05). Transferred patients had more than a twofold increase in intensive care unit use, however, and a substantial increase in total costs.9 The options for Tasmania are to develop two public acute hospital units each with two surgeons (one in Launceston and one in Hobart) or a single public acute hospital unit, with an outreach service to the North as currently applies.

7 Dimick J, Pronovost PJ, Cowan JA, Ailawadi G, Upchurch GR Jnr. The volume-outcome effect for abdominal aortic surgery. Arch Surg. 2002;137: 828-832. 8 Norman PE, Semmens JB, Lawrence-Brown MMD, Holman CDJ. Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study. BMJ 1998;317:852-856. 9 Vogel T R, Nackman G B, Brevetti L S, Crowley J G, Bueno M M, Banavage A, Odroniec K, Ciocca R G, Graham A M. Resource utilisation and outcomes: effect of transfer on patients with ruptured abdominal aortic aneurysms. Annals of Vascular Surgery 2005;19(2):149-153.

44 Clinical Services Plan: Update Vascular surgery There is no doubt that from a sustainability perspective the optimal service (continued) configuration is a unit of four surgeons located in a single unit in Hobart. This configuration avoids the well-recognised problems associated with single- or dual- surgeon practice. On the other hand, it jeopardises access for residents of the North and North West regions, particularly for time-critical emergencies including ruptured abdominal aortic aneurysm and for urgent surgery including vascular access procedures for patients undergoing renal dialysis, and increases travel distances for elective surgery. On balance, the existing arrangement of four vascular surgeons located in Hobart and providing outreach service to the North (and, if possible, the North West) should be maintained. Appointment of a single surgeon to the LGH would not create a sustainable service, and disruption of the established Hobart service, which is well-structured, in order to provide a local service in the North may result in two unsustainable services and a diminution of service to the entire State. Where possible, patients with medical complications of vascular illness (e.g. ulcers) should be managed within their local services with vascular specialist oversight.

Implementation commitment 13 By December 2008 the Department will facilitate: • formal agreement between the LGH, the NWRH (Burnie) and the RHH on the scope of and accountability arrangements for vascular surgery provision to the LGH and the NWRH; and • the development of formal protocols for the rapid transfer from the North and North West regions directly to theatre at the RHH of patients with time-critical vascular emergencies who are considered suitable for surgery.

Clinical Services Plan: Update 45 Integrated care centres

Commitment to develop purpose-built facilities for integrated care Tasmania’s Health Plan announced the proposed development of four ICCs in the following locations: • collocated with the RHH; • on Hobart’s eastern shore; • in Launceston, close to the LGH; and • in Kingborough.

ICCs were described in the Plan as facilities which: • accommodate a range of health services that provide efficient, integrated care regardless of who funds, owns or provides each element of the services; • operate under a philosophy which is less interventional and oriented towards care in the community rather than institutional care; and • provide greater certainty of access for clients because they focus on non-emergency services including a broad range of non-admitted primary, secondary and tertiary services, short stay elective services and specialised sub-acute services.

These purpose-built facilities will enable distinctive physical, funding and administrative arrangements to be implemented to support a desired model of care. The first step in the detailed planning of Tasmania’s ICCs, however, requires precise definition of the concept of ‘integrated care’ and clear specification of the objectives of developing purpose-built facilities for its delivery to ensure that the opportunities presented by these developments are captured optimally.

Integrated care – a definition Some definitions of integrated care focus on the organisation of services across different sectors, for example:

‘…a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors.’10

Other definitions focus on the provision of a broad range of health and/or social care services:

‘…a concept bringing together inputs, delivery, management and organisation of services related to diagnosis, treatment, care, rehabilitation and health promotion.’11

The need for integrated care The following trends highlight the need for better integrating care: • the Tasmanian population is ageing and suffers from a relatively high incidence of chronic conditions which require different health care solutions than do acute conditions. The emphasis is shifting from acute interventions to monitoring and from cure to care. There is a requirement for multidisciplinary teamwork in order to optimally manage these conditions; and • increasingly, hospitals are providing short stay, high technology treatment, with a need for an increasing range of services to be provided in non-hospital settings.

10 Kodner, DL.; Spreeuwenberg, C. Integrated care: meaning, logic, applications, and implications – a discussion paper. International Journal of Integrated Care , Vol 2 < http://www.ijic.org/>. 11 Gröne, Garcia-Barbero. WHO European Office for Integrated Health Care Services. International Journal of Integrated Care [serial online]. 2001 Jun 1;1 < http://www.ijic.org/>.

46 Clinical Services Plan: Update Integrated care has been identified as a means of addressing a number of failings of modern health care systems including: • lack of ‘ownership’ of patients and their problems, so that information gets lost as patients navigate the system; • lack of involvement by the user/patient in the management and strategy of care; • poor communication with the user/patient as well as with health and social care providers; • treating patients with one condition without recognising other needs or conditions, thereby undermining the overall effectiveness of treatment; and • decisions made in the social care setting affect the impact of health care treatment, and vice versa.12

Patient care is increasingly encompassing more technologically sophisticated multidisciplinary care which is provided in multiple settings, requiring more and better coordination and integration. Vulnerable groups who have difficulty accessing the health care system (e.g. people with chronic disabling conditions who are isolated, dependent, frail and/or mentally ill) are recognised as having particular needs for integrated care.

Increasingly, governments are seeking to integrate health and social care, with the system of care designed around the patient rather than the organisations that deliver care. Integrated care has the objective of providing seamless, coordinated care from the perspective of the patient.

Types of integration of health care Shortell distinguishes integration at various levels: • functional integration occurs on the macro-level of a health care system, for example through mainstreaming of the financing and regulation of cure, care, prevention and social services; • organisational integration occurs on the meso-level of a health care system, for example in the form of mergers, contracting or strategic alliances between health care institutions; • professional integration occurs on the meso-level of a health care system, for example in the form of mergers (e.g. group practices), contracting or strategic alliances between health care professionals; and • clinical integration occurs on the micro-level of a health care system, for example continuity, cooperation and coherence in the primary process of care delivery to individual patients.13

Depending on its philosophy, funding models and structure, an ICC may have a range of characteristics. For example it may be a facility: • in which a single organisation owned and operated by the Tasmanian Government (e.g. a hospital or community health service) provides a broad range of health and/or social care services, enabling the coordinated provision of prevention, treatment and care in a non-hospital setting; • in which multiple providers (e.g. publicly and privately employed professionals in the health and social care sectors) collocate and practise their professions, not changing their organisational arrangements or methods of service delivery, but creating enhanced referral opportunities and enabling consumers to access multiple types of care in a single setting; or • in which multiple providers work together in a coordinated manner to enable the delivery of ‘seamless’ care to patients.

12 Lloyd J and Wait S. Integrated care: a guide for policymakers. Alliance for Health and the Future, London. Accessed on 13 April 2008. . 13 Shortell SM, Gillies RR, Anderson DA, Erikson KM, Mitchell JB. Remaking Health Care in America. San Francisco, Jossey Bass Publishers. 2000.

Clinical Services Plan: Update 47 The outcomes of such arrangements may be integration from the perspective of providers; integration from the perspective of consumers (who experience ‘seamless’ care); or integration from the perspective of both providers and consumers (see Figure 5 below).

Figure 5: Types of integrated care

High Provider integration

Models of integrated care can be located in different parts of the matrix

Low User integration

Low High

Source: Lloyd J and Wait S. Integrated care: a guide for policymakers14

There is an opportunity for the Tasmanian health care system to develop physical facilities and governance and management arrangements that best support integrated care, complementing the current acute and primary health care systems while ensuring that patient access to existing resources is maintained.

Early work has identified the following key objectives in relation to ICCs in Tasmania: • provision of well-integrated, multidisciplinary, patient-centred care across the primary and acute sectors; • responsiveness to local community needs and priorities; • accessible, culturally appropriate and affordable care; • more effective prevention and management of chronic conditions; • a working environment and conditions that attract and retain workforce; and • provision of high quality education and training opportunities to support the future health workforce.

ICCs will improve the patient’s experience and outcome of care by: • diverting patients from an acute care destination/facility to a more appropriate setting of care; and • providing more effective prevention and management of chronic conditions, through planned, managed and proactive care that reduces complications and prevents or delays relapse.

A number of issues need to be considered as detailed planning for the ICCs progresses: • what is the purpose of each ICC? Options include direct service delivery from a central site; the provision of a ‘front door’ to a number of diverse providers who may or may not be located on site; the coordination of services for target patient groups; and/or the provision of support to health care professionals to enable them to provide better integrated care for their patients.

14 Lloyd J and Wait S. Integrated care: a guide for policymakers. Alliance for Health and the Future, London. Accessed on 13 April 2008. . 15 ibid.

48 Clinical Services Plan: Update As an example of a ‘front door’ model, in the Netherlands a ‘one window’ model applies to users of health and social care, which provide advice, information and support in accessing and utilising health and social care services;15 • who are the target patient groups? People with chronic illness (especially those who are at risk of hospitalisation or who require intermittent acute care in the management of a chronic condition) are a clear target group. Other target groups may include elderly people; people with defined health and/or social vulnerabilities; and/or people recently discharged from hospital; • what types of providers should be engaged and what is the purpose of the engagement? For example, provision of a broad range of care, facilitation of referral pathways, or influencing changes in practice; • which specific providers should provide services from each ICC? Options include state-owned and funded providers only (e.g. public acute hospitals and/or community health centres) through to providers of privately owned and operated services including general practice, allied heath, health promotion/illness prevention organisations and/or local government; • what processes will link those providers together? For example, common philosophies, funding streams, employment arrangements, reporting/accountability arrangements, contractual agreements; • who should be engaged in planning and managing each ICC? • what organisational structure is appropriate, recognising that the structure can define the ways in which professionals and patients are engaged in achieving each ICC’s objectives?

Decisions about these and other relevant issues will need to be reached as planning for Tasmania’s ICCs proceeds.

Effective planning and management of these facilities will enable many patients, particularly those with chronic and complex conditions, to receive multidisciplinary care that will reduce their need for inpatient care and enable better management of their health and wellbeing.

Implementation commitment 14 The Department will convene a multidisciplinary ICC policy and planning group immediately to develop, consult on and finalise a policy and planning framework for ICCs by July 2008, that will support a subsequent detailed model of care and facility planning.

Clinical Services Plan: Update 49 Efficiency and accessibility of hospital services

Introduction When planning for the future, it is usual to start from a baseline of current activity and adjust it for expected changes in a range of parameters including population growth and ageing and changes in models of care.

It is also useful to consider the following questions before assuming that the current baseline of service delivery is appropriate: • Is the overall investment in health services reasonable? • Is that investment applied efficiently, to get the best value for the community? • Is that investment distributed fairly, so that all members of the community have reasonable opportunities to access services according to their needs?

This section of the report considers Tasmania’s health investment compared with other states and territories; indicators of whether resources are used efficiently; and the way in which resources are distributed within Tasmania.

Benchmarking Tasmania’s resources The Australian Institute of Health and Welfare publishes a range of benchmarking data, the most recent of which relates to public acute hospitals for the financial year 2005–06. These data show that Tasmania has: • the highest total beds (public, private and psychiatric) per 1,000 population of any Australian jurisdiction (it should be noted that these figures include the relatively large number of beds in very small rural hospitals in Tasmania, a model which is uncommon in other jurisdictions); • an average number of public acute and psychiatric hospital beds per 1,000 resident population; • the lowest number of public hospital separations and a relatively low number of patient days per 1,000 population; • a high average length of stay, both overall and when same day patients are excluded; • a high average cost weight per separation; • a higher-than-average cost per casemix-adjusted separation; • an average rate of potentially preventable hospitalisations; and • higher-than-average access to aged care places and packages (Table 17).

50 Clinical Services Plan: Update Table 17: Benchmarking data, Tasmania’s hospitals 2005–06

NSW Vic Qld WA SA Tas ACT NT Total Total beds per 3.9 3.7 4.1 4.2 4.6 4.6 3.4 3.5 4.0 1,000 population(1) Avail. beds to 1,000 2.9 2.4 2.5 2.5 3.2 2.7 2.2 2.8 2.7 resident population(2) Separations per 199.8 243.7 187.9 195.7 228.4 185.8 238.4 483.0 212.8 1,000 population(3) Patient days per 780.8 810.4 661.3 703.1 838.3 716.3 823.2 1,504.7 768.8 1,000 population(3) Average length of 4.0 3.4 3.5 3.6 3.9 4.0 3.4 2.9 3.7 stay (days)(3) Average length of stay 6.3 6.4 5.9 6.2 6.6 6.9 6.3 5.8 6.3 excluding same day(3) Average cost weight 1.06 0.95 1.00 0.98 1.00 1.05 1.03 0.74 1.00 of separations(3) Total cost per casemix- 4,006 3,785 3,738 3,842 3,334 4,109 4,380 4,223 3,839 adjusted separation (including depreciation)(4) Teaching hospitals cost 4,150 3,802 3,902 3,841 3,444 4,063 4,380 4,135 3,940 per casemix-adjusted sep (including depreciation) Residential aged care 101.0 105.6 101.8 100.5 111. 0 105.1 96.1 108.3 103.3 and transition care places, CACPs and EACH packages per 1,000 persons aged 70+

(1) Public acute, public psychiatric and private hospitals. (2) Public acute and psychiatric hospitals. (3) Public acute hospitals only. (4) Psychiatric hospitals, drug and alcohol services, mothercraft hospitals, unpeered and other, hospices, rehabilitation facilities, small non-acute hospitals and multi-purpose services are excluded from this table. The data are based on hospital establishments for which expenditure data were provided, including networks of hospitals in some jurisdictions. Some small hospitals with incomplete expenditure data were not included. Source: AIHW Australian Hospital Statistics 2005–06. AIHW Residential Aged Care in Australia 2005–06. Using resources efficiently – benchmarking length of stay Inter-jurisdictional data from 2006–07 were used to compare the average length of stay at Tasmanian hospitals with interstate peer hospitals.

If each Tasmanian public acute hospital was able to achieve the length of stay of the best-performing peer hospitals for high volume diagnosis-related groups (DRGs), 15,307 fewer overnight bed days would be required. In total, this would equate to 49.7 beds at 85 per cent occupancy with 16.5 beds at the NWRH (Burnie), 12.1 beds at the Mersey Community Hospital, 7.9 beds at the LGH and 13.2 beds at the RHH.

In terms of the best practice hospital, the NWRH (Burnie) had 1 DRG, Mersey Community Hospital had no DRGs, the LGH had 9 DRGs and the RHH had 5 DRGs of their top 25 DRGs as best practice.

The same analysis was performed at the state level. This analysis shows 10,011 fewer overnight bed days would be required if Tasmanian hospitals were able to achieve best practice. In total, this would equate to 32.3 beds at 85 per cent occupancy. Tasmania had no DRGs of its top 25 as best practice, while Queensland, Victoria and the ACT each had 8 and the Northern Territory had 1.

Clinical Services Plan: Update 51 Using resources efficiently – potentially avoidable hospital admissions Ambulatory Care Sensitive Conditions (ACSCs) are those for which hospitalisation is thought to be avoidable if preventive care and early disease management are applied, usually in an ambulatory setting.16 In theory, access to timely and effective ambulatory care can reduce the risks of hospitalisation, thereby ensuring that care is provided in appropriate settings and that scarce hospital resources are used appropriately.

Tasmania’s rate of potentially preventable hospitalisations is comparable to rates in other jurisdictions (Table 18).

Table 18: Potentially preventable hospitalisations, age-standardised, per 1,000 population

NSW Vic Qld WA SA Tas ACT NT Total Separation rates 27.83 31.70 32.07 46.76 32.71 31.23 21.86 47.29 31.98 for potentially preventable hospitalisations

Source: AIHW Australian Hospital Statistics 2005–06.

In 2006–07, Tasmania had 17,922 admissions for ACSCs, a reduction of 282 or two per cent compared with 2005–06. There was growth in ACSC admissions in both the NWRH (Burnie) and the LGH between 2005 and 2007. Each of the LGH and the RHH accounted for more than 40 per cent of the total ACSC admissions in Tasmania in 2006–07 (Table 19).

Table 19: ACSC admissions by hospital 2006–07

Hospital 2005–06 2006–07 Diff % Change % of total (2006–07) NWRH (Burnie) 1,496 1,629 133 9% 9% NWRH (Mersey) 1,328 1,250 -78 -6% 7% LGH 7,227 7,340 113 2% 41% RHH 8,153 7,703 -450 -6% 43% Grand Total 18,204 17,922 -282 -2% 100%

The greatest numbers of ACSC admissions were for diabetes complications, chronic obstructive pulmonary disease and angina.

The length of stay and ACSC analyses suggest there are opportunities to improve the efficiency of Tasmania’s public acute hospitals. The Department will work with each of the acute hospitals and other relevant stakeholders to ensure that public acute hospital resources are used efficiently and to enhance secondary preventive care, thereby systematically reducing admissions for the management of ACSC.

Implementation commitment 15 Commencing mid-2009, the Department will monitor and report annually on a range of benchmarking data including lengths of stay and the rate of admissions for Ambulatory Care Sensitive Conditions.

16 Chronic Disease Surveillance & Epidemiology Section, Public Health, Department of Human Services (2006). Ambulatory care sensitive conditions 2004–05 update: (including Primary Care Partnerships and Local Government Areas). Melbourne, Victoria. Victorian Government.

52 Clinical Services Plan: Update Regional utilisation rates Within Tasmania, residents from different regions do not appear to have equal access to acute hospital resources (see Table 24 on page 58). Analysis of separation rates confirms that:

• in absolute terms residents of the North (259 separations per 1,000 persons) and North West (249 separations per 1,000 persons) enjoyed better access to public hospital inpatient services in Tasmania than residents of the South (224 separations per 1,000 persons) in 2006–07; • there is relatively higher access in the South to private hospital services, followed by the North and North West; and • overall, residents of the South (406 separations per 1,000 persons) had better access to hospital services than residents of the North (364 separations per 1,000 persons) and residents of the North West (318 separations per 100 persons) in 2006–07.

The Victorian public hospital utilisation rate for 2006–07 was 264 admissions per 1,000 population. The comparable Tasmanian rate was 239 admissions per 1,000 population. Only residents of the North (259 separations per 1,000 persons) have similar access to Victorians. More than 12,000 additional public hospital separations (and approximately an additional 100 beds) across the State would be required to achieve a public hospital utilisation rate comparable to that of Victoria.

It is likely that differential investment will be required to improve access by residents of the North West to inpatient services. Approximately 6,200 additional admissions of people from the North West (an increase of almost 18%) annually would be required to achieve the current statewide average of 375 separations (public and private) per 1,000 persons per year in the North West region. Some of this investment may occur in the private sector and some also may be appropriate in the North and South regions to enable the LGH and the RHH to provide more services to patients from the North West. Development of services locally is consistent with the principles underpinning this Plan and should be the goal providing that they can be developed on a sustainable basis.

The 2007 Clinical Services Plan recognises the critical role that the private sector plays in the overall provision of health services to Tasmanians. A reduction in service capability by the private sector results in increasing demand pressure on the public sector. The Clinical Services Plan proposes a strategic approach to private sector relationships with a focus on the way the public and private sectors work together for the overall benefit of the community.

Alternatively (and recognising that Victoria has had a higher public hospital utilisation rate than almost all other jurisdictions) Tasmania could choose to invest differentially in out-of-hospital care, particularly for people with chronic diseases, limiting the need for additional inpatient services.

Implementation commitment 16 As well as investing strategically in public admitted and non-admitted services for the communities of the North West region, the Department will work with the private sector to determine ways to develop appropriate private sector inpatient services for the region’s communities.

Implementation commitment 17 By February 2009 the Department will establish a Health Industry Forum with participation by the private sector, and work with the private sector to facilitate the cooperative development of Tasmania’s health services for the overall benefit of the community.

Clinical Services Plan: Update 53 Implementation commitment 18 Commencing mid-2009, the Department will monitor and publish regional utilisation rates regularly.

Regional self-sufficiency Self-sufficiency refers to the extent to which patients who require health services access them in their region. It is an indicator of the degree to which services are accessible to people close to where they live – one of the important principles on which the 2007 Clinical Services Plan is based and to which the Tasmanian Government maintains a strong commitment (providing services are able to be designed for sustainability).

In 2006–07 a number of services had low self-sufficiency within the North West region including interventional cardiology, haematology, medical oncology, chemotherapy and radiotherapy, renal medicine, cardiothoracic surgery, neurosurgery, urology, extensive burns, tracheostomy and sub- acute services. In some clinical areas this low level of self-sufficiency is appropriate – for example interventional cardiology, cardiothoracic surgery, neurosurgery and extensive burns services require a much larger population base to support a quality service than exists in the North West, and it is appropriate that residents travel to Launceston, Hobart or interstate for these services. In other clinical areas, such as urology, chemotherapy and sub-acute services, it should be possible to improve self-sufficiency through the development of new services on either a local or outreach basis. The Clinical Services Plan supports the development of these services.

The North region has a high self-sufficiency for most specialties. Self-sufficiency for cardiothoracic surgery and neurosurgery appropriately is low as these services are provided from the RHH. Vascular surgery also has low self-sufficiency. There is debate about whether complex vascular surgery should be available locally in the North of the State – this issue is discussed earlier in this report (see pages 44–45).

The South catchment had high self-sufficiency for all specialties.

Despite relatively low levels of self-sufficiency in some sub-specialty services in some regions, Tables 22 and 23 demonstrate that in 2006–07: • 76 per cent of public hospital separations within Tasmania and 74 per cent of all public hospital separations (within Tasmania and interstate) utilised by residents of the North West in 2006–07 were provided by the NWRH (Burnie or Mersey campuses or via public contracts) or to dialysis patients treated by the LGH in the North West region. If services such as renal dialysis, chemo/ radiotherapy and obstetrics are excluded from this analysis (the high volume of these services and in some cases multiple episodes per patient tend to distort the analysis) the level of self- sufficiency in the North West is approximately 70 per cent; • almost 90 per cent of all public hospital separations within Tasmania and 87 per cent of all public hospital separations (within Tasmania and interstate) utilised by residents of the North West were provided in the North West or North; • the LGH (including the public contract for ophthalmology services) provided 13 per cent of the separations within Tasmania utilised by residents of the North West; • fewer than 6 people in every 100 from the North West and fewer than 4 people in every 100 from the North who received public acute hospital inpatient care in the State accessed that care at the RHH – and 29 per cent of these patients from the North and 32 per cent of these patients from the North West were admitted to the RHH as emergencies;

54 Clinical Services Plan: Update • the LGH (including the public contract for ophthalmology services) provided almost 88 per cent of public hospital separations within Tasmania and 86 per cent of all public hospital separations (within Tasmania and interstate) utilised by residents of the North; • there was a very high level of self-sufficiency for public acute hospital services in the South of the State – the RHH (including the public contract for ophthalmology services) provided almost 96 per cent of public hospital separations within Tasmania and 94 per cent of all public hospital separations (within Tasmania and interstate) utilised by residents of the South; • just over 300 patients from the South were admitted to the LGH for elective care. In contrast, more than 1,900 patients from the North West and North of the State were referred to the RHH for elective admission; and • there was little ‘leakage’ from any region for public acute hospital services interstate – fewer than 2 in 100 Tasmanian patients received their public hospital care from interstate public hospitals.

Tables 22 and 23 demonstrate that: • most Tasmanian residents received their public hospital inpatient care during 2006–07 in the region in which they live. The most significant out-of-region provision of care was by the LGH to residents of the North West; and • very few Tasmanian residents accessed public hospital care in interstate hospitals.

The existing self-sufficiency of the North and combined North and North West, which approaches 90 per cent, and the self-sufficiency of the South in the mid-90 per cent compare favourably with a commonly accepted benchmark of 85 per cent self-sufficiency for public hospital inpatient services in regional areas.

There are opportunities to improve self-sufficiency levels in the North West by increasing services in key areas such as short stay surgery, chemotherapy, radiotherapy, renal dialysis, sub-acute care and rehabilitation as proposed in the 2007 Clinical Services Plan. Many of these services could be provided locally or on an outreach basis from Launceston if workforce challenges can be overcome. Outreach services need to be planned and negotiated as services are developed, and each service development opportunity in Hobart and Launceston needs to be reviewed to determine whether an element of the service could be provided on an outreach basis to improve self-sufficiency in the North West.

There are no proposals in the 2007 Clinical Services Plan which would reduce self-sufficiency. The Plan provides for all existing services to be maintained in existing locations. Where new services are developed, self-sufficiency will be a priority if services can be provided safely, efficiently and at acceptable cost in more than one region. If, however, services need to be concentrated for sustainability, then it is in the community interest that this occurs.

Equity of regional investment During the consultation for this Clinical Services Plan update, many clinicians from the LGH expressed concern about equity of funding between the LGH and the RHH.

A detailed review of the equity of funding between Tasmania’s acute hospitals was beyond the scope of this Clinical Services Plan update. Ensuring equity of funding is a complex matter that depends on a range of factors including community need, variation in the complexity of services provided (which is highest for same day patients in the LGH and highest for multi-day patients in the RHH – see Tables 20 and 21 below); the costs of providing services on an outreach basis by the RHH and the LGH; cost burdens associated with recruitment and retention (which are significant in the North West); the cost of teaching and training (which varies between hospitals depending on their roles); and the cost of delivering non-admitted patient services (which also varies considerably between hospitals).

Clinical Services Plan: Update 55 Table 20: % of same day patients by complexity number and hospital 2006–07

Complexity NWRH NWRH LGH RHH Tasmania Victoria No (Burnie) (Mersey) 0 6% 5% 2% 3% 3% 11% 1 70% 64% 57% 59% 59% 60% 2 17% 23% 23% 28% 25% 23% Non-complex 94% 92% 82% 89% 87% 94% 3 5% 6% 13 % 8% 9% 5% 4 1% 1% 4% 3% 3% 1% 5 0% 0% 1% 0% 0% 0% 6 0% 0% 0% 0% 0% 0% 7 0% 0% 0% 0% 0% 0% 8 0% 0% 0% 0% 0% 0% Complex 6% 8% 18% 11% 13% 6%

Table 21: % of multi-day patients by complexity number and hospital 2006–07

NWRH NWRH LGH RHH Tasmania Victoria (Burnie) (Mersey) Complexity % ALOS % ALOS % ALOS % ALOS % ALOS % ALOS No seps seps seps seps seps seps 0 1% 1.7 8% 2.9 7% 3.2 5% 2.7 5% 4.2 5% 3.3 1 50% 4.0 49% 3.5 46% 4.8 38% 3.9 45% 5.6 41% 3.5 2 22% 5.0 20% 5.4 22% 5.5 25% 5.2 23% 6.5 22% 4.6 Non- 73% 4.3 77% 3.9 75% 4.8 68% 4.3 73% 5.8 68% 3.8 complex 3 13 % 9.2 12% 9.7 11% 11. 0 15% 10.8 13 % 11. 6 13 % 6.8 4 7% 11.7 6% 13.5 6% 15.6 8% 12.6 7% 13.5 8% 9.4 5 4% 17.4 3% 15.5 3% 21.4 4% 16.4 4% 18.4 5% 12.3 6 2% 17.3 1% 21.1 2% 26.1 2% 20.6 2% 22.1 3% 15.3 7 1% 32.7 1% 28.1 1% 29.2 1% 33.3 1% 31.8 2% 19.0 8 1% 31.7 0% 32.8 1% 36.5 1% 37.6 1% 36.4 2% 30.4 Complex 28% 10.0 23% 10.0 25% 13.4 32% 11.4 28% 12.7 32% 11.0

There is a clear need for funding to be both equitable and transparent and for hospital managers and clinicians to be accountable for using resources efficiently.

Implementation commitment 19 The Department will aim to maintain and improve equity of resource distribution between regions; accountability of hospitals for their efficient operation; and regional self-sufficiency of acute hospital services. Annual self-sufficiency targets will be established immediately in all regions and performance against targets will be monitored and reported annually. A detailed study of cost modelling and resource allocation benchmarks will be completed to establish, after factors such as patient complexity and region-specific costs have been taken into account, a mechanism to ensure equity in future resource allocations.

The Department’s aim will be to ensure that each hospital accesses a fair proportion of the State’s overall hospital investment and uses it efficiently for the best benefit of the community.

56 Clinical Services Plan: Update Total 7,558 7,002 91,967 12,108 50,516 15,787 85,413 34,897 184,939 14% 75% 59% 82% 79% 72% 77% 80% 65% % public 2,138 1,591 7,016 3,287 6,525 13,964 36,824 20,980 Private 64,329 115 214 581 631 302 state 1,212 1,054 Inter- public 2,267 suffi- 87.6% 58.4% 95.8% 72.6% 75.8% 88.8% ciency % self- 88.6% All seps 1,033 9,756 1,356 3,940 public 12,198 35,971 27,250 63,221 54,089 118, 343 5 15 79 34 Tas 1,531 1,425 1,479 2,784 4,263 5,873 Other 2 4 6 13 17 16 52 36 176 234 South public contract 71 519 447 208 725 RHH 1,273 1,523 2,796 51,638 54,881 5 3 13 49 66 40 107 554 447 623 public North contract 317 196 568 577 LGH 1,052 1,640 3,456 31,049 34,505 35,399 4 6 10 118 407 NW 1,703 2,234 2,228 public 2,248 contract 33 48 213 348 5,414 1,078 7,053 6,840 7,134 NWRH NWRH (Mersey) 17 64 183 123 1,969 2,724 6,888 11,764 11, 581 11,951 NWRH NWRH (Burnie) Mersey NorthTotal West Catchment Central Coast (Mersey) North North/Total North West South Burnie Central Coast (Burnie) Interstate Total Total Separations Note: Of the Central Coast residents who presented to the NWRH, 25.6%25.6% presented of Central to the Coast NWRH (Mersey) residents and reside 74.4% presented in the Mersey to the NWRH catchment (Burnie). and 74.4% reside For in the Renal the purposes Burnie17 dialysis catchment. of calculating separations current performed self-sufficiency in Burnie in 2006–07 it has been assumed are attributed that to NWRH (Burnie). Table 22:Table 2006–07Tasmanian admission flows to hospitalsregionby

Clinical Services Plan: Update 57

318 375 364 406 Total 5,005 36,188 64,977 25,446 131,616 All separations/ 16% 74% 54% 64% 59% per 1,000 persons 1,000 per % public

64 131 178 101 Private Private 4,212 6,489 12,683 29,520 Private 52,904 separations/ 1,000 persons 1 542 463 900 state Inter- public 1,906

249 259 239 224 Public suffi- separations/ 70.4% 95.6% 84.3% ciency % self- 86.1% 1,000 persons All 792 seps 353 public 18,415 34,557 23,042 76,806 50,516 98,140 34,897 183,906 184,939 75 Tas 1,015 All separations 1,223 2,279 4,592 Other 1 5 16 36 631 581 161 218 1,054 2,267 2,267 South public contract Tasmanian in interstate public hospitals 333 residents treated 1,315 RHH 1,092 32,890 18 35,630 352 7,016 3 13,964 42,997 66 64,329 Private Private 64,329 102 615 444 public North separations contract 345 250 LGH 2,771

18,970 22,336 1,033 Public 35,971 27,250 54,089 117, 310 118, 343 1 157 158 separations NW public contract 32 48

161 5,457 5,698 NWRH NWRH 241,650 138,702 (Mersey) 109,570 489,922 489,922 Population 78 79 48 7,354 7,559 NWRH NWRH (Burnie) Acute admissions excluding renal dialysis, chemo/radiotherapy, obstetrics,geriatric qualified evaluation and unqualified and management neonates and rehabilitation because their very services high numbers are also tend excluded to distort because underlying they tend to be provided trends. on a regional Mental basis health, and require palliative a different care, nursing planning approach.home-type care, Interstate residents treated in Tasmanian hospitals Grand Total Catchment Catchment Total North West LGA unrecordedLGA North South North North West South Interstate Total Total Separations 18 24: 2006–07Table utilisation rates regional by population Table 23: 2006–07Table acuteTasmanian admission flows to hospitalsregionby

58 Clinical Services Plan: Update Access to emergency department services Analysis of emergency department attendances and the availability of general practitioners (GPs) demonstrates significant differences across the State (Table 25).

Table 25: Emergency department utilisation and general practitioner availability

Hospital Referral ED Presentations Relative ED No. of ED Relative GP Population presentations /1000 utilisation presentations availability 2006 2006–07 population 2006–07 above or 2005–06 2006–07 below average 2006–07 NWRH 57,114 24,438 428 1.7 10,102 0.83 (Burnie) NWRH 48,645 21,753 447 1.8 9,543 (Mersey) LGH 135,404 34,409 254 1.0 423 0.88 RHH 235,330 39,062 166 0.7 -20,006 1.15 Total 476,493 119,662 251 1.0

The North West region has a significantly higher rate of service utilisation than the average for the State.

Application of resources to emergency department presentations which could be provided more effectively in other settings is not an efficient use of acute hospital resources. Emergency department utilisation rates correlate negatively with the availability of GPs. There is a relative shortage of 22 GPs in the North West and 20 GPs in the North and a relative excess of 41 GPs in the South. If an additional 22 GPs were available in the North West, each would need to undertake only 893 consultations per year (approximately 19 per week) to eliminate the ‘excess’ presentations to the emergency departments of the North West hospitals.

The Australian Government’s commitment to fund GP Superclinics in Devonport and Burnie provides a significant opportunity to develop facilities which will enable GPs to practise within supportive multidisciplinary primary health care teams.

Implementation commitment 20 The Department will collaborate with the Australian Government, Divisions of General Practice and other relevant organisations to develop a ‘whole-of-state’ strategy for general practice. Key objectives of the strategy will be recruitment of general practitioners to the North West region to ensure more equitable access to general practice services; and the development of new models of support for general practice – including community-based and practice-based nurses – to ensure service sustainability. The strategy will be completed by December 2009.

Clinical Services Plan: Update 59 Predicting future demand

Planning on the basis of current patient flow patterns, self-sufficiency levels and hospital service profiles provides base predictions about the overall number of beds and other facilities that are likely to be required across the system.

Assumptions can then be made about changes in service profiles and patient flows to provide a prediction of the resources that will be required in each of Tasmania’s public acute hospitals in the future, as each of the hospital’s roles and referral populations changes.

If current patient flow patterns, self-sufficiency and hospital service profiles remain constant, population growth and ageing are the main factors that will influence future hospital service requirements.

Projection datasets for this project were developed for the Department by Hardes and Associates.19

Planning on this basis demonstrates that there will be a steady increase over the coming years in admissions to Tasmania’s public acute hospitals (Figure 6).

It should be noted that predictions made using this methodology do not take into account any existing maldistribution of resources within Tasmania’s health care system.

Figure 6: Predicted admissions to Tasmania’s public acute hospitals

200000200,000 180000180,000 160000160,000 140000140,000 120000120,000 100,000

Separations 100000 8000080,000 6000060,000 4000040,000 2000020,000 00 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021 Year

19 Hardes and Associates, January 2008.

60 Clinical Services Plan: Update Table 26: Projected separations 2006–07 – 2021–22

Hospital 2006–07 2011–12 2016 –17 2021–22 Difference % change % p.a. NWRH 11,951 13,488 15,127 16,937 4,986 42% 2.4% (Burnie) NWRH 7,134 7,656 8,157 8,666 1,532 21% 1.3% (Mersey) LGH 35,399 42,348 48,261 54,339 18,940 54% 2.9% RHH 54,881 63 , 611 71,745 80,378 25,497 46% 2.6% Other public 8,978 9,763 10,551 11,431 2,453 27% 1.6% hospitals Interstate 2,267 2,755 3,094 3 ,411 1,144 50% 2.8% Grand Total 120,610 139,621 156,935 175,162 54,552 45% 2.5%

Note: Renal dialysis separations performed in Burnie in 2006–07 are attributed to the NWRH (Burnie).

The largest number of additional separations will be for residents of Launceston, Clarence and Hobart. The LGAs with the largest expected percentage growth in separations are Kingborough and Meander Valley.

The need for services for older people (nursing home-type care, rehabilitation and geriatric evaluation and management) is predicted to grow the most, whereas the service categories of gynaecology, obstetrics and unqualified (normal) neonates are expected to decline the most.

A requirement for an additional 67 same day beds and an additional 345 multi-day beds across the State by 2016–17 is predicted.

Figure 7: Actual and projected multi-day beds by specialty (top and bottom 10)

300300

250250

200200

150150

100100 Calculated multi-day beds 5050

00 GEM NHT Psychiatry Obstetrics Neurology Cardiology Gynaecology Dermatology Renal Dialysis Rehabilitation Orthopaedics Neurosurgery Palliative Care Rheumatology GeneralMedicine Ear, Nose & ThroatEar, Unqualified Neonate Unqualified Respiratory Medicine Head & Neck Surgery Chemo & Radiotherapy

2006–07 2016–17

Clinical Services Plan: Update 61 Under this model, increases of 34 multi-day beds at the NWRH (Burnie), 17 at the Mersey Community Hospital; 87 at the LGH; and 130 at the RHH are predicted (Table 27). Five additional same day beds will be required at the NWRH (Burnie); 2 at the Mersey Community Hospital; 26 at the LGH; and 33 at the RHH.

Table 27: Calculated beds by hospital

2006–07 2016 –17 Difference Hospital Same day Multi-day Same day Multi-day Same day Multi-day beds beds beds beds beds beds NWRH (Burnie) 15 105 20 139 5 34 NWRH (Mersey) 8 82 10 99 2 17 LGH 53 319 79 406 26 87 RHH 87 451 120 581 33 130 Other 3 288 4 365 1 77 Grand Total 166 1,245 233 1,590 67 345

Note: Renal dialysis separations performed in Burnie in 2006–07 are attributed to the NWRH (Burnie).

Tasmania is projected to require 17.6 operating theatres by 2016–17. This represents an increase of 2 theatres over the number of theatres utilised in 2006–07 (Table 28). Access to an additional 0.4 elective multi-day and 0.7 emergency multi-day theatres, 0.2 endoscope suites and 0.7 same day suites will be required over the next ten years. There is spare theatre capacity available across the State, however, and existing physical operating theatre space is expected to be sufficient to meet these future requirements.

Table 28: Calculated theatres by hospital

2016 –17 Difference 2006–07 to 2016–17 Operating NWRH NWRH LGH RHH NWRH NWRH LGH RHH Theatres (Burnie) (Mersey) (Burnie) (Mersey) Elective MD 0.6 0.7 1.8 2.6 0.0 0.1 0.2 0.1 Emergency MD 0.6 0.3 2.2 2.3 0.0 0.0 0.4 0.3 Endoscopy Suites 0.2 0.2 0.8 1.0 0.0 0.0 0.1 0.1 SD 0.5 0.6 1.4 1.8 0.0 0.1 0.3 0.3 Grand Total 1.9 1.8 6.2 7.7 0.0 0.2 1.0 0.8

Across the State, emergency department activity is projected to increase by more than 25,000 presentations in the next ten years (Table 29):

Table 29: Emergency department forecast presentations by hospital

Hospital 2006–07 2016 –17 Difference % p.a. growth NWRH (Burnie) 24,578 27,847 3,269 1.3% NWRH (Mersey) 21,894 24,935 3,041 1.3% LGH 34,409 42,071 7,662 2.0% RHH 38,848 50 , 611 11,763 2.7% Grand Total 119,729 145,464 25,735 2.0%

Methods of estimating acute treatment spaces in emergency departments vary between the States. NSW uses one treatment space per 1,460 presentations,20 whereas Victoria uses one treatment space per 1,300 presentations as a benchmark.

20 Activity Planning Guideline for Emergency Department Services, NSW Health, Statewide Services Development Branch, Planning Series, November 2006.

62 Clinical Services Plan: Update Treatment spaces also can be estimated by the number of patients who are admitted from the emergency department.21 The NSW benchmark is one treatment space per 400 admissions through the emergency department excluding renal dialysis, chemotherapy and unqualified neonates. While this may be an appropriate benchmark for the RHH and the LGH it is not appropriate for the NWRH (Burnie) or the Mersey Community Hospital because of their known high rate of presentations of non-admitted patients.

Table 30 demonstrates the number of emergency department spaces which would be required according to the different benchmarks that could be applied (one treatment space per 1,460 presentations; one treatment space per 1,300 presentations; or one treatment space per 400 admissions from the emergency department). Regardless of which method of estimating future resource requirements is used, it appears that there will not be enough actual emergency department spaces to meet the projected demand. By 2016–17, approximately 20 additional treatment spaces will be required.

Table 30: Emergency department calculated treatment spaces

2006–07 2016 –17 Difference Available Benchmark 1460 1300 400 1460 1300 400 1460 1300 400 spaces 2008 NWRH (Burnie) 17 19 11 19 21 13 2 2 2 12 NWRH (Mersey) 15 17 6 17 19 8 2 2 2 8 LGH 24 26 29 29 32 37 5 6 8 20 RHH 27 30 38 35 39 46 8 9 8 41 Total 83 92 84 100 111 104 17 19 19 81

The NSW benchmark of one treatment space per 1,460 presentations is appropriate for the RHH and the LGH, suggesting that in 2016–17 they will require 35 and 29 emergency department treatment spaces respectively, compared to a current calculated requirement of 27 and 24 spaces respectively. The LGH emergency department is shown to be under the greatest pressure and, depending on the configuration of services that is agreed for the ICC, expansion may be warranted.

The high proportion of low complexity presentations at the NWRH (Burnie) and the Mersey Community Hospital means that these benchmarks are not appropriate – in those settings a higher number of presentations per treatment space is feasible and it may be more appropriate to design multi-purpose consulting spaces to accommodate a higher throughput of patients.

21 Australasian College for Emergency Medicine, Emergency Department Design Guidelines, October 1998.

Clinical Services Plan: Update 63 Meeting the needs of the community – the future service system

Introduction The 2007 Clinical Services Plan is based on a fundamental redesign of Tasmania’s public acute hospital services in the North West. In broad terms, it proposes consolidation on the Burnie campus of all high acuity services for the North West, with the Mersey campus providing a viable mix of complementary services and the two campuses, in aggregate, providing a comprehensive range of services for the population of the North West.

The service configuration for the North West region proposed in the 2007 Clinical Services Plan is presented in Table 31.

Table 31: 2007 Clinical Services Plan proposals, NWRH

NWRH (Burnie) NWRH (Mersey) Intensive care Theatre recovery and emergency resuscitation support Inpatient acute medical Specialist aged care (admitted and non-admitted), subacute, rehabilitation and transition care Inpatient acute surgical Up to 23-hour acute elective surgical Low and medium risk obstetrics Low risk obstetrics Ante-natal and post-natal care (admitted and non- Ante-natal and post-natal care (admitted and admitted) non-admitted low risk) Inpatient paediatrics Short stay paediatrics (12 hours) Emergency medicine Emergency care centre, 24 hours, 7 days a week Satellite renal dialysis (Parkside) Satellite renal dialysis (new service) Day chemotherapy Day chemotherapy Specialty and sub-specialty consulting Specialty and sub-specialty consulting

Key proposals in the 2007 Clinical Services Plan also include the development of new and the expansion of existing services at the NWRH (Mersey) including cancer services, day surgery, renal dialysis, aged care and rehabilitation.

The Tasmanian Government believes that the changes proposed in the 2007 Clinical Services Plan represent the most appropriate approach to meeting the health needs of Tasmanians generally and the communities of the North West in particular. Given the intervention of the Australian Government in the North West it is, however, necessary to adapt the Clinical Services Plan to accommodate the changed ownership arrangements for the Mersey Community Hospital.

If the new operators are unable to deliver health care services of an acceptable range and quality, the Tasmanian Government would consider resuming responsibility for the Mersey Community Hospital. This would be on the basis of a service model consistent with the principles of the 2007 Clinical Services Plan, with the addition of extra services described in Model 1 (outlined on page 70) providing these services continue to be sustainable.

Nevertheless, in the context of the current ownership and proposed operating arrangements for the Mersey Community Hospital, the Australian and Tasmanian Governments have expressed a firm commitment to working together to develop an integrated and sustainable service system for the community of the entire North West region.

64 Clinical Services Plan: Update Planning sub-catchments for the North West region For planning purposes, the catchment of the North West region has been further categorised as the catchment of the NWRH (Burnie) (comprising Burnie, Circular Head, King Island, Waratah/Wynyard, West Coast and 50% of Central Coast) and the catchment of the Mersey Community Hospital (comprising Devonport, Kentish, Latrobe and 50 per cent of Central Coast).

The predicted population changes in these sub-regions are presented in Table 32 (noting that predicted populations are likely to be underestimated – see discussion commencing on page 5).

Table 32: Population changes in North West sub-catchments

NWRH (Burnie) sub-catchment Mersey Community Hospital sub-catchment LGA 2006 2016 Diff % LGA 2006 2016 Diff % popl’n popl’n popl’n popl’n Burnie 18,640 17,550 -1,090 -6% Central 10,351 9,821 -530 -5% Coast 50% Central 10,351 9,821 -530 -5% Devonport 24,048 22,960 -1,088 -5% Coast 50% Circular 7,860 7,240 -620 -8% Kentish 5,526 5,451 -75 -1% Head King Island 1,667 1,579 -88 -5% Latrobe 8,720 9,428 +708 +8% Waratah/ 13,452 12,892 -560 -4% Wynyard West Coast 5,144 4,346 -798 -16% Total 57,114 53,428 -3,686 -6% 48,645 47,660 -985 -2%

It should be noted that both the NWRH (Burnie) and the LGH have been meeting a significant proportion of the public acute hospital needs of the residents of the Mersey Community Hospital referral area. Excluding residents of the Central Coast, the NWRH (Burnie) provided almost 2,000 admissions for residents of the Mersey sub-catchment in 2006–07. In the same period, the NWRH (Mersey) provided less than 350 admissions for residents of the Burnie sub-catchment and the LGH provided 1,640 admissions for residents of the Mersey sub-catchment, compared with 1,052 admissions for residents of the Burnie sub-catchment (see Table 22 on page 57).

If the Australian Government is successful in maintaining the Mersey Community Hospital as a full service community hospital, current levels of regional self-sufficiency would be expected, at a minimum, to be maintained and an aim of improving regional self-sufficiency would be reasonable.

A single hospital for the North West region Many stakeholders are concerned that the Mersey Community Hospital will remain unsustainable as a full service general community hospital. Some stakeholders believe that a new single campus regional hospital in a central location between Burnie and Mersey, possibly at Ulverstone, is now the only achievable solution to the problems of sustainability of health services in the North West.

There is no doubt that a single regional public acute hospital complemented by a distributed service system of community-based services serving a regional community of more than 100,000 people would be positioned to provide more efficient, effective and sustainable services, enabling concentration of scarce human and physical resources on a single site for the benefit of the community.

There are a number of issues that need to be considered carefully in relation to this proposal. The NWRH (Burnie) is housed in a modern, purpose built and functional building and is collocated with the University of Tasmania’s Rural Clinical School which provides a critically important hub for clinical

Clinical Services Plan: Update 65 teaching and research in the North West. Community reaction to a potential relocation of the NWRH (Burnie) and the Mersey Community Hospital has not been tested. To progress the proposal for a single hospital, detailed consideration would need to be given to the most appropriate location to meet the needs of a very dispersed regional community extending to the far West and North West coasts. A site which is chosen mainly because it is in a ‘neutral’ geographic area may not be the most appropriate site to meet the health needs of the community.

Should the Tasmanian Government decide to progress the development of a single-site regional hospital in the future, a full planning assessment of the best location for that hospital and the potential operational benefits that would be achieved should be conducted.

The 2007 Clinical Services Plan was developed on the basis of a continuation of the two campus model for the NWRH. In the absence of identified capital for the development of a new single hospital with complementary community-based services, this update assumes that both the NWRH (Burnie) and the Mersey Community Hospital will continue to deliver inpatient services from their current sites.

Planning for an integrated service system in the North West region The 2007 Clinical Services Plan was designed to address the challenges facing Tasmania’s health care system in a systematic and sustainable manner. The change in ownership of the Mersey Community Hospital, however, has hampered implementation of the Plan in the North West and necessitated a review of the strategies proposed in that Plan.

The fragmentation of ownership of the public acute hospitals in the North West region increases the potential for service duplication, service gaps and cost-shifting between the parties with potential impacts on the NWRH (Burnie) and the LGH. The Tasmanian Government is committed to minimising potential problems related to hospital ownership by planning and delivering services carefully in accordance with the agreed roles of the hospitals and in a spirit of cooperation and accountability.

As well as their responsibilities for providing hospital services, both the Australian and Tasmanian Governments fund and/or provide a vast range of community-based services – the Australian Government via programs such as Medicare and the Pharmaceutical Benefits Scheme and the Tasmanian Government via hospital outreach programs and community health programs. Ensuring appropriate clinical integration across all community- and hospital-based programs in the North West is a key objective for the Tasmanian Government.

Detailed, hospital-specific service plans will need to be developed for the NWRH (Burnie), the LGH and the Mersey Community Hospital with the objective of providing an appropriate range and volume of services for the communities of the North and North West regions. Service sustainability will be a priority.

It is likely to be in the community interest for some services to be consolidated on one site in the North West region, by agreement between the governments and/or hospitals – for example: • the 2007 Clinical Services Plan proposes consolidated sub-acute inpatient rehabilitation, aged care and transition care services for the North West region, based at the NWRH (Mersey); • the region’s orthopaedic surgeons already are working together to provide a whole-of-region service, with low complexity patients being treated at both the Mersey Community Hospital and the NWRH (Burnie) and patients needing a higher level of support being treated at the NWRH (Burnie); • for some time, medium risk obstetric services have been provided in Burnie alone, while low risk obstetric services have been provided in both communities; and • recently, managers and clinicians at the NWRH (Burnie) have agreed to provide anaesthetic services to support some surgical services at the Mersey Community Hospital.

66 Clinical Services Plan: Update This shared services concept was the basis of the 2007 Clinical Services Plan for the North West region and should continue to be explored where it may be beneficial to the community and where it is consistent with the Australian Government’s aspirations for the Mersey Community Hospital and the Tasmanian Government’s aspirations for the NWRH (Burnie) and the Tasmanian health system generally.

Implementation commitment 21 The Tasmanian Government adopts the following principles to underpin planning and delivery of hospital services in the North West region: • A balanced mix and appropriate volume of high quality public acute hospital services should be available to all residents of the North West region. Responsibility for providing these services will be shared by the Australian and Tasmanian Governments. • The Australian Government will be responsible for providing an appropriate range and volume of safe, high quality community hospital services to the residents of the referral area of the Mersey Community Hospital. The Tasmanian Government will license the Mersey Community Hospital in accordance with its usual licensing standards for private hospitals, but otherwise recognises that the Australian Government (or its delegates) will plan and be accountable for the role and service profile of the Mersey Community Hospital. • Residents of the Mersey Community Hospital referral region who need complex acute services which do not fit within the agreed service profile of the Mersey Community Hospital will be able to access such services through the State hospital system at Burnie, Launceston or Hobart. It will be important for the Mersey Community Hospital to deliver an agreed range and volume of services to its referral community so that the Tasmanian Government can deliver the necessary complementary higher complexity services in a planned and equitable manner. • The Tasmanian Government will be responsible for providing an appropriate range and volume of public acute hospital services to the referral communities of the NWRH (Burnie). • Resources such as specialist staff; diagnostic services; theatre facilities; clinical governance functions such as audit; and purchasing functions could be shared between the NWRH (Burnie) and the Mersey Community Hospital, if such sharing would benefit the community and can be agreed between the Department and the operators of the Mersey Community Hospital. • Some services may be developed on a whole-of-region basis by agreement between the Australian and Tasmanian Governments.

When a patient presents to a Tasmanian hospital, their access to treatment should not be influenced by where they live. Patients from the Mersey Community Hospital referral area who elect to access services in Burnie or Launceston, or vice versa, should be treated solely in accordance with their clinical need.

At the same time, both the Tasmanian and Australian Governments will wish to improve self- sufficiency in the North West region and demonstrate appropriate accountability to the community for their investments in public acute hospitals in the North West region.

It is not possible to define, up to a decade in advance, the exact range and volume of services that will be required by the communities of the North West – all planning predictions will be subject to modification over time as local circumstances change. Nevertheless, this Plan provides the basis by which the performance of both the NWRH (Burnie) and the Mersey Community Hospital can be monitored and reported to the Australian Government, the Tasmanian Government and the community.

Clinical Services Plan: Update 67 The Tasmanian Government, in collaboration with the Australian Government, will develop a performance monitoring and reporting framework for the NWRH (Burnie) and the Mersey Community Hospital which will ensure that each party provides a suitable range and volume of public acute hospital services of an appropriate level of complexity, consistent with their commitments to the community. The framework will include measures of: • the range and volume of services in each Major Clinical Related Group (MCRG) provided by the NWRH (Burnie), the Mersey Community Hospital and other providers and compared with predicted need. For example, actual activity can be tracked against predicted activity shown in Table 34 on page 72 and Table 35 on page 73; • trends in the mix of simple and complex services provided by NWRH (Burnie), the Mersey Community Hospital and other providers. A hospital could, for example, provide a high volume of simple surgical procedures but not meet its community’s need for lower volume, higher complexity services, even though such services could be provided appropriately in that setting. Services can be monitored for complexity in a variety of ways. Tables 20 and 21 on page 56 describe the relative complexity of same day and multi-day services provided by Tasmania’s public acute hospitals in 2006–07, an indicator which can be monitored over time. Other measures of complexity include the percentage of same day and multi-day patients, and ‘weighted’ separations where the resource usage of each episode is calculated using a standardised weighting measure;22 and • the extent to which a region or sub-region is self-sufficient for hospital services. This is a helpful aggregate measure of whether a suitable range and volume of services of appropriate complexity is being provided. Table 22 on page 57 provides a basis for monitoring whether the NWRH (Burnie) and the Mersey Community Hospital are maintaining acceptable levels of self-sufficiency for their sub-catchment populations.

For each indicator, the Mersey Community Hospital and the NWRH (Burnie) performance will be compared with underlying trends in demand and service provision and with the performance of other Tasmanian public acute hospitals and peer hospitals to ensure that their performance is consistent with contemporary practice.

Implementation commitment 22 The Department will develop a detailed clinical service profile for the NWRH (Burnie) in consultation and cooperation with the Australian Government and/or the operator of the Mersey Community Hospital with the objective of ensuring sustainable services on a whole- of-region basis. Subject to the timely completion by the Australian Government of a service plan for the Mersey Community Hospital, the NWRH (Burnie) clinical service profile will be developed by December 2008.

Implementation commitment 23 The Tasmanian Government will seek to agree on a robust performance monitoring and reporting framework with the Australian Government to ensure that both the NWRH (Burnie) and the Mersey Community Hospital contribute equitably to the provision of an integrated health service for the region.

22 A weighted separation is a measure of the complexity of a hospital separation using average weights for episodes that have the same diagnosis and treatment, based on nationally accepted Diagnosis Related Groups (DRGs).

68 Clinical Services Plan: Update Planning assumptions for the North and North West regions The planning projections presented earlier in this report (commencing on page 60 under the heading ‘Predicting Future Demand’) assume that current patterns of activity will continue at each of Tasmania’s public acute hospitals, changing only in response to population growth and ageing.

In the following section some activity is redistributed on the assumption that the service system will develop in a different direction from the past as a result of the change in ownership of the Mersey Community Hospital and implementation of the access and sustainability principles underpinning the 2007 Clinical Services Plan.

Two models are presented. In the context of the current fragmented ownership of the public acute hospitals in the North West, the Tasmanian Government prefers the first model (Model 1). It is similar to the service model proposed in the 2007 Clinical Services Plan, but in addition to providing for the Mersey Community Hospital to be a regional centre for certain services for residents of the North West (including high volume day surgery, rehabilitation and aged care), it enables medical patients with low to medium complexity conditions and paediatric patients with low complexity conditions to be cared for as inpatients at the Mersey Community Hospital. Inpatient surgery is not conducted at the Mersey Community Hospital under this model.

The second model (Model 2) provides for the Mersey Community Hospital to become a full service community hospital. This model is not preferred by the Tasmanian Government because, for reasons explained in the 2007 Clinical Services Plan and earlier in this report, it is likely to be unsustainable. Nevertheless it has been modelled because it is consistent with announcements made by the Australian Government about the future of the Mersey Community Hospital.

The two models present revised projections of activity at each of the public acute hospitals in the North West and the LGH. Both are based on the following common assumptions about where patients will access care: • total demand is that projected by the Hardes and Associates forecast model base case (January 2008); • the allocation model includes separations within Tasmania, including interstate inflows and public contracts with private services. Private sector separations not funded by public agencies and interstate separations are not included in the following figures; • no changes are made to flows in public contracts; • flow percentages to the private sector and interstate inflows and outflows will not change; • flow percentages to smaller facilities and the RHH will not change, with the exception that major vascular surgery will be concentrated at the RHH; • services provided under the NWRH contract are considered to be services of the NWRH (Burnie); • dialysis services provided currently in Burnie by the LGH are modelled as services of the NWRH (Burnie); • low risk obstetric services will be provided at the Mersey Community Hospital with higher risk obstetric patients referred to Burnie; • low risk paediatric inpatient services will be provided at the Mersey Community Hospital with higher risk paediatric patients referred to Burnie; • vascular surgical procedures provided to residents of the North West region will be provided at the RHH. It is anticipated that some procedures, for example amputations, will be undertaken by vascular surgeons visiting the LGH and the NWRH (Burnie) and incorporated within year-to-year planning and resource allocations;

Clinical Services Plan: Update 69 • the Mersey Community Hospital will have a high dependency unit; • hip and knee joint replacements for residents of the North West region will be provided at the NWRH (Burnie); and • most interventional cardiology services for residents of the North West region will be provided at the LGH. Model 1 incorporates the following additional assumptions: • the Mersey Community Hospital will become a referral centre for same day surgery. Services for 40 per cent of same day surgery patients from the NWRH (Burnie) referral area, 15 per cent of same day surgery patients from the LGH referral area and 90 per cent of same day surgery patients from the Mersey Community Hospital referral area will be provided by the Mersey Community Hospital. Although not incorporated into Model 1, there is also potential for some patients from the RHH referral area to receive their same day surgery at the Mersey Community Hospital, consistent with the principles established in the 2007 Clinical Services Plan; • all specialist aged care, sub-acute, rehabilitation and transition care for residents of the North West region will be provided at the Mersey Community Hospital; • general medical inpatients with conditions requiring care of low complexity will be admitted to the Mersey Community Hospital. Medical patients requiring care of higher complexity will be referred to the NWRH (Burnie) or the LGH as appropriate; and • all patients from the referral area of the Mersey Community Hospital requiring inpatient surgery with a length of stay of more than 24 hours will be referred to the NWRH (Burnie) (with the exception of a small number of patients who will require referral to the LGH or the RHH). Model 2 incorporates the following additional assumptions: • the Mersey Community Hospital will provide a full range of low to medium complexity medical and surgical inpatient services to residents of its referral area; • the Burnie and Mersey sub-catchments will be self-sufficient for rehabilitation services. It should be noted that on current demand projections, both the NWRH (Burnie) and the Mersey Community Hospital will require fewer than 10 beds. Further planning is required to determine appropriate service capacity and models of care for rehabilitation services; • no changes have been made to the locations of geriatric evaluation and management and nursing home-type patients in the North West region; • the NWRH (Burnie) will provide higher complexity services for residents of the North West region with the Mersey Community Hospital focusing on sub-regional community hospital-type services for the Mersey Community Hospital catchment (Devonport, Kentish, Latrobe and 50 per cent of Central Coast). The LGH will provide regional high complexity and specialist services for the North West and North regions; and • the distributions are the same for same day and multi-day separations.

Table 33 demonstrates the differences between the three planning models (the 2007 Clinical Services Plan model and the two new planning models, Model 1 and Model 2).

70 Clinical Services Plan: Update Table 33: Mersey Community Hospital and NWRH (Burnie) assumed service profile

2007 Clinical Services Plan Model 1 Model 2 NWRH Mersey NWRH Mersey NWRH Mersey (Burnie) Community (Burnie) Community (Burnie) Community Hospital Hospital Hospital Intensive care Theatre Intensive care Theatre Intensive care Theatre recovery and recovery recovery emergency and high and high resuscitation dependency dependency support unit unit Inpatient acute Regional Inpatient acute Low complexity Inpatient acute Low to medium medical specialist aged medical inpatient medical, local complexity care (admitted acute medical, specialist aged inpatient acute and non- regional care, sub-acute, medical, local admitted), specialist aged rehabilitation specialist aged sub-acute, care, sub-acute, and transition care, sub-acute, rehabilitation rehabilitation care rehabilitation and transition and transition and transition care care care Inpatient acute Up to 23-hour Inpatient acute Up to 23-hour Inpatient acute Low to medium surgical acute elective surgical acute elective surgical risk inpatient surgical surgical acute surgical Low and Low risk Low and Low risk Low and Low risk medium risk obstetrics medium risk obstetrics medium risk obstetrics obstetrics obstetrics obstetrics Ante-natal and Ante-natal and Ante-natal and Ante-natal and Ante-natal and Ante-natal and post-natal care post-natal care post-natal care post-natal care post-natal care post-natal care (admitted and (admitted and (admitted and (admitted and (admitted and (admitted and non-admitted) non-admitted non-admitted) non-admitted non-admitted) non-admitted low risk) low risk) low risk) Inpatient Short stay Inpatient Low risk Inpatient Low risk paediatrics paediatrics paediatrics inpatient paediatrics inpatient (12 hours) paediatrics paediatrics Emergency Emergency Emergency Emergency Emergency Emergency medicine care centre, medicine care centre, medicine care centre, 24 hours, 7 24 hours, 7 24 hours, 7 days a week days a week days a week Satellite Satellite renal Satellite Satellite renal Satellite Satellite renal renal dialysis dialysis (new renal dialysis dialysis (new renal dialysis dialysis (new (Parkside) service) (Parkside) service) (Parkside) service) Day Day Day Day Day Day chemotherapy chemotherapy chemotherapy chemotherapy chemotherapy chemotherapy Specialty and Specialty and Specialty and Specialty and Specialty and Specialty and sub-specialty sub-specialty sub-specialty sub-specialty sub-specialty sub-specialty consulting consulting consulting consulting consulting consulting

It should be noted that these assumptions are made for planning purposes only – the Australian Government is responsible for planning the range and volume of services to be provided by the Mersey Community Hospital, but these assumptions are necessary because that planning was not concluded at the time this Clinical Services Plan update was completed.

The figures labelled ‘2006–07 reallocated’ represent a theoretical distribution of current services if they were to be distributed according to the allocation model, and are intended to distinguish volume changes due to shifts in service locations from volume changes due to future growth of service demand.

Clinical Services Plan: Update 71 Planned acute hospital activity, 2016–17 Tables 34 and 35 (below) present expected acute hospital activity under Model 1 and Model 2.

Table 34: Modelled activity, 2016–17, Model 1

MCRG NWRH NW Mersey LGH North RHH South Other Grand (Burnie) public Comm- public public Total contract unity contract contract Hospital Breast 59 68 135 165 <5 429 Surgery Cardiology 1,056 6 584 2 ,110 2,899 <5 604 7,261 Cardiothoracic 38 448 486 Surgery Chemo & 511 570 2,497 6,103 121 9,801 Radiotherapy Colorectal 195 130 398 321 <5 <5 1,046 Surgery Dentistry 65 62 182 <5 413 724 Dermatology 39 59 132 312 40 582 Diagnostic GI 541 680 2,464 3,091 6,776 Endoscopy Drug & 252 <5 84 617 1,073 462 2,489 Alcohol Ear Nose & 169 115 540 <5 778 88 1,690 Throat Endocrinology 212 105 511 9 1,116 196 2,149 Extensive 29 70 6 105 Burns Gastro- 265 <5 289 1,283 1,546 431 3,815 enterology GEM 108 19 74 849 113 1,163 Gynaecology 444 464 777 <5 953 <5 17 2,656 Haematology 190 302 1,641 3,018 174 5,325 Head & Neck 31 7 68 119 226 Surgery Immunology 174 <5 87 690 14 1,048 197 2,212 & Infections Interventional 2,098 1,381 3,479 Cardiology Medical 219 96 725 <5 1,425 224 2,690 Oncology Mental Health <5 <5 <5 Neurology 497 <5 404 1,571 26 2,535 505 5,539 Neurosurgery 58 <5 33 146 425 <5 31 697 NHT 149 96 220 677 422 1,565 Non 583 19 660 1,953 16 4,981 247 683 9,142 Subspecialty Medicine Non 776 <5 449 2,002 3,286 394 6,910 Subspecialty Surgery

72 Clinical Services Plan: Update MCRG NWRH NW Mersey LGH North RHH South Other Grand (Burnie) public Comm- public public Total contract unity contract contract Hospital Non-acute <5 <5 Obstetrics 195 1,118 422 2,580 <5 3,280 <5 140 7,737 Ophthalmology 26 131 319 515 516 710 8 2,226 Orthopaedics 1,420 658 2,162 <5 3,044 <5 208 7,496 Pain 232 250 473 1,275 155 2,385 Management Palliative care 32 10 140 16 434 632 Plastics/ 189 <5 304 554 <5 890 9 1,949 Reconstructive Surgery Psychiatry 570 59 926 8 1,931 12 418 3,924 Qualified 29 248 43 466 0 814 <5 29 1,631 Neonate Rehabilitation <5 <5 <5 Acute Rehabilitation <5 294 558 1,083 56 1,993 Sub-acute Renal Dialysis 2,751 2,541 9,549 11, 851 26,692 Renal 53 91 470 789 67 1,470 Medicine Respiratory 737 <5 472 1,694 88 2,068 <5 699 5,761 Medicine Rheumatology 45 55 113 <5 664 48 928 Tracheostomy 41 89 168 298 Unallocated 12 6 81 <5 113 23 236 Unqualified 50 429 287 1,013 <5 1,207 53 3,039 Neonate Upper GI 223 96 533 620 63 1,534 Tract Surgery Urology 156 182 1,469 78 1,339 14 90 3,327 Vascular 34 118 363 1,028 74 1,618 Surgery Grand Total 13,387 1,962 11,572 46,648 772 71,924 285 7,292 153,842

Table 35: Modelled activity, 2016–17, Model 2

MCRG NWRH NW Mersey LGH North RHH South Other Grand (Burnie) public Comm- public public Total contract unity contract contract Hospital Breast 59 55 148 165 <5 429 Surgery Cardiology 969 6 647 2 ,116 2,899 <5 623 7,261 Cardiothoracic 38 448 486 Surgery Chemo & 511 570 2,497 6,103 121 9,801 Radiotherapy Colorectal 153 144 426 321 <5 <5 1,046 Surgery Dentistry 67 62 180 <5 413 724

Clinical Services Plan: Update 73 MCRG NWRH NW Mersey LGH North RHH South Other Grand (Burnie) public Comm- public public Total contract unity contract contract Hospital Dermatology 48 52 130 312 40 582 Diagnostic GI 602 816 2,267 3,091 6,776 Endoscopy Drug & 239 <5 87 625 1,073 464 2,489 Alcohol Ear Nose & 136 122 564 <5 778 89 1,690 Throat Endocrinology 198 126 503 <5 1,116 198 2,149 Extensive <5 28 70 6 105 Burns Gastro- 284 <5 239 1,308 1,546 436 3,815 enterology GEM 73 21 104 849 115 1,163 Gynaecology 512 317 853 <5 953 <5 19 2,656 Haematology 175 169 1,776 3,018 187 5,325 Head & Neck 18 12 77 119 226 Surgery Immunology 145 <5 137 669 14 1,048 197 2,212 & Infections Interventional 2,098 1,381 3,479 Cardiology Medical 131 107 798 <5 1,425 229 2,690 Oncology Mental Health <5 <5 <5 Neurology 456 <5 398 1,584 26 2,535 540 5,539 Neurosurgery 39 <5 39 153 425 <5 37 697 NHT 130 125 208 677 424 1,565 Non Subspec 567 19 593 2,024 16 4,981 247 695 9,142 Medicine Non Subspec 592 <5 569 2,058 <5 3,286 401 6,910 Surgery Non-acute <5 <5 Obstetrics 110 1,118 657 2,412 3,280 <5 157 7,737 Ophthalmology 59 131 195 606 516 710 8 2,226 Orthopaedics 1,259 726 2,244 4 3,044 <5 218 7,496 Pain 289 183 482 1,275 157 2,385 Management Palliative care 13 18 151 16 434 632 Plastics/ 374 <5 60 613 <5 890 9 1,949 Reconstructive Surgery Psychiatry 546 66 940 8 1,931 12 421 3,924 Qualified 19 248 74 444 814 <5 29 1,631 Neonate Rehabilitation <5 <5 <5 Acute Rehabilitation 137 139 567 1,083 67 1,993 Sub-acute

74 Clinical Services Plan: Update MCRG NWRH NW Mersey LGH North RHH South Other Grand (Burnie) public Comm- public public Total contract unity contract contract Hospital Renal Dialysis 2,751 2,541 9,549 11,851 26,692 Renal Medicine 57 57 500 789 67 1,470 Respiratory 553 <5 515 1,839 88 2,068 <5 695 5,761 Medicine Rheumatology 55 39 111 <5 664 55 928 Tracheostomy 18 <5 109 168 298 Unallocated 9 <5 9 2 <5 113 20 236 Unqualified 32 429 364 955 <5 1,207 52 3,039 Neonate Upper GI 145 149 557 620 63 1,534 Tract Surgery Urology 272 128 1,403 78 1,339 14 93 3,327 Vascular 34 93 394 1,020 76 1,618 Surgery Grand Total 12,838 1,962 11,418 47,200 772 71,916 285 7,451 153,841

Note: Figures differ by one separation compared to Model 1, due to rounding.

Planning outcomes for the North West Regional Hospital (Burnie) Under both models, it is envisaged that the service profile of the NWRH (Burnie) will remain unchanged from that proposed in the 2007 Clinical Services Plan. The hospital will continue to provide intensive care, inpatient and day-stay acute medical and surgical care (including all joint replacements for patients from the North West region), low and medium risk obstetric, ante-natal and post-natal care, inpatient paediatric care, emergency medicine, a satellite renal dialysis service (supported on an outreach basis by clinicians from the LGH), chemotherapy and a broad range of specialist and sub-specialist consulting.

Both models predict significant growth in the number of patients requiring overnight admissions to the NWRH (Burnie) and an associated growth in total beds, to 183 beds under Model 1 and 163 beds under Model 2. In comparison to Model 2, Model 1 provides for almost 1,750 more multi-day admissions, 24 more multi-day beds, almost 1,200 fewer same day admissions and 4 fewer same day beds in the NWRH (Burnie).

The NWRH (Burnie) currently has a substantial number of acute bed spaces used for non-clinical purposes, and spare theatre capacity. On these estimates, the facility will have capacity to meet inpatient growth needs for the near future, but may have capacity limitations towards the end of the planning period, particularly under Model 1. It should be noted that the assumed development of sub-acute services at the Mersey Community Hospital will relieve pressure on the largest demand growth area. There is no change in same day bed requirements under Model 1 and a modest increase under Model 2, but it should be noted that same day chemotherapy activity is not reported in the NWRH (Burnie) data and growth would be anticipated in this service under both models.

The modelled distribution of services under both models also does not take into account the relatively lower access to inpatient services for residents of the North West which was identified earlier in this report. While additional growth in inpatient services may be necessary, there is an opportunity for the Tasmanian Government to invest differentially in community-based services for people with chronic disease to redress this apparent inequity in access over the planning period.

Clinical Services Plan: Update 75 Table 36: Modelled distribution NWRH (Burnie) 2006–07 and 2016–17, Model 1

2006–07 2006–07 2006–07 2006–07 2016 –17 2016 –17 2016 –17 actual re- NW Total NWRH NW Total NWRH allocated public NWRH (Burnie) public NWRH (Burnie) NWRH contract (Burnie) contract (Burnie) (Burnie) Seps Day Only 6,333 3,851 584 4,435 5,702 625 6,327 Seps 5,618 7,102 1,664 8,766 7,685 1,337 9,022 Overnight Total 11,951 10,953 2,248 13,201 13,387 1,962 15,349 Bed days Day 6,333 3,851 584 4,435 5,702 625 6,327 Only Bed days 32,686 39,280 5,659 44,939 48,074 4,459 52,533 Overnight Total 39,028 43,131 6,243 49,374 53,776 5,084 58,860 Same day 15 9 2 11 13 2 15 beds Multi-day beds 105 126 19 145 154 14 168 Total Beds 120 135 21 156 167 16 183

Note: Bed totals have been rounded for clarity.

Table 37: Modelled distribution NWRH (Burnie) 2006–07 and 2016–17, Model 2

2006–07 2006–07 2006–07 2006–07 2016 –17 2016 –17 2016 –17 actual re- NW Total NWRH NW Total NWRH allocated public NWRH (Burnie) public NWRH (Burnie) NWRH contract (Burnie) contract (Burnie) (Burnie) Seps Day Only 6,333 4,894 584 5,478 6,891 625 7,516 Seps 5,618 5,438 1,664 7,102 5,947 1,337 7,283 Overnight Total 11,951 10,332 2,248 12,580 12,838 1,962 14,799 Bed days 6,333 4,894 584 5,478 6,891 625 7,516 Day Only Bed days 32,686 31,820 5,659 37,479 40,731 4,459 45,190 Overnight Total 39,028 36,714 6,243 42,957 47,622 5,084 52,706 Same day beds 15 13 2 15 17 2 19 Multi-day beds 105 102 18 120 129 15 144 Total Beds 120 115 20 135 146 17 163

Planning outcomes for the Mersey Community Hospital Model 1 provides for the Mersey Community Hospital to deliver a high proportion of day surgery for the region together with regional specialist aged care, sub-acute, rehabilitation and transition care services, consistent with the planned service profile under the 2007 Clinical Services Plan. In contrast with the 2007 Clinical Services Plan it also provides for inpatient care for medical and paediatric patients who require low complexity care and a high dependency unit consistent with the recommendation of the recent review. This is the preferred model.

Model 2 assumes that the Mersey Community Hospital will provide a full range of community hospital-type services, as described earlier in this report, supported by a high dependency unit.

76 Clinical Services Plan: Update Both models assume that all joint replacement surgery will be conducted at the NWRH (Burnie) and that most specialist vascular procedures will be undertaken at the RHH.

Under both models, there is a modest growth in beds at the Mersey Community Hospital – to 95 under Model 1 and to 118 under Model 2. The number of patients treated at the Mersey Community Hospital is approximately equal under both models, but Model 2 provides for a greater focus on multi-day patients while Model 1 provides for a greater focus on same day patients.

Under both models there appears to be sufficient demand to support a small satellite or home dialysis service for the referral population of the Mersey Community Hospital, as proposed in the 2007 Clinical Services Plan.

Table 38: Modelled distribution Mersey Community Hospital 2006-07 and 2016-17, Model 1

2006–07 Actual 2006–07 Re-allocated 2016–17 Total Seps Day Only 2,224 5,997 8,468 Seps Overnight 4,910 2,641 3,105 Total 7,134 8,638 11, 572 Bed days Day Only 2,224 5,997 8,468 Bed days Overnight 26,248 15,223 23,573 Total 28,472 21,220 32,041 Same day beds 8 18 23 Multi-day beds 81 46 72 Total Beds 89 64 95

Table 39: Modelled distribution Mersey Community Hospital 2006-07 and 2016-17, Model 2

2006–07 Actual 2006–07 Re-allocated 2016–17 Total Seps Day Only 2,224 4,036 6,102 Seps Overnight 4,910 4,768 5,316 Total 7,134 8,804 11,418 Bed days Day Only 2,224 4,036 6,102 Bed days Overnight 26,248 24,891 32,795 Total 28,472 28,927 38,897 Same day beds 8 11 15 Multi-day beds 81 76 103 Total Beds 89 87 118

Planning outcomes for the Launceston General Hospital In both models, by 2016–17, the LGH shows strong growth in same day and overnight separations.

Total separations at the LGH in both models are comparable with the 2007 Clinical Services Plan which predicted 45,898 total separations compared with approximately 47,000 in these models, but a longer average length of stay has resulted in an overall increase in bed requirements compared with those predicted in 2007. In both models there is a requirement for more than 20 additional same day beds and almost 100 additional multi-day beds.

Detailed service-level planning for the Launceston ICC will commence shortly after the publication of this Clinical Services Plan update. It is likely that some same day beds which are included in projections for the LGH will be provided in the ICC, leading to a reduction in same day bed requirements for the LGH.

Clinical Services Plan: Update 77 Table 40: Modelled distribution LGH 2006–07 and 2016–17, Model 1

2006–07 Actual 2006–07 Re-allocated 2016–17 Total LGH Seps Day Only 20,834 19,700 29,315 Seps Overnight 14,565 15,187 17,332 Total 35,399 34,887 46,647 Bed days Day Only 20,834 19,700 29,315 Bed days Overnight 101,565 104,712 132,693 Total 122,399 124,412 162,008 Same day beds 53 50 73 Multi-day beds 318 328 416 Total Beds 371 378 489

Note: Renal dialysis separations performed in Burnie in 2006–07 are attributed to the NWRH (Burnie).

Table 41: Modelled distribution LGH 2006–07 and 2016–17, Model 2

2006–07 Actual 2006–07 Re-allocated 2016–17 Total LGH Seps Day Only 20,834 20,462 30,265 Seps Overnight 14,565 14,807 16,934 Total 35,399 35,269 47,199 Bed days Day Only 20,834 20,462 30,265 Bed days Overnight 101,565 103,188 131,151 Total 122,399 123,650 161,416 Same day beds 53 53 76 Multi-day beds 318 323 411 Total Beds 371 376 487

Note: Renal dialysis separations performed in Burnie in 2006–07 are attributed to the NWRH (Burnie).

Planning outcomes for the Royal Hobart Hospital

The core objectives of the new RHH are: • focus on delivery of acute care services (non-acute and support services will be collocated only where this is the most appropriate and sustainable option); • be part of and support an integrated health system (including public acute hospitals, ICCs, statewide clinical services networks, and primary health and community care); • provide a contemporary standard of acute patient care (through delivery of quality services in a healing environment that is adaptable to need and recognises patients as individuals); • support clinical education and advance clinical research; • be designed for a sustainable future; and • be an integral part of the community.

The redistribution model applied above alters the patient flows in the North of the State but does not impact on planning projections for the South, except for an additional requirement to provide for vascular procedures for the North West region, estimated at 170 separations or three multi-day beds.

Demand growth in the South will relate to population growth and ageing rather than to changes in patient flows, unless there are significant changes in flows of patients from the private to the public sector or vice versa.

78 Clinical Services Plan: Update As noted earlier in this report (see discussion commencing on page 60), a major increase in demand for services is predicted in the South, with separations increasing by 31 per cent from 54,881 in 2006–07 to 71,745 in 2016–17. Increases of 33 same day beds and 130 multi-day beds are predicted to be required to meet this demand.

A large component of the predicted increased demand relates to non-acute inpatient services – including rehabilitation, geriatric evaluation and management, transition care and palliative care – which are projected to increase dramatically over the planning period. The most significant growth will be seen in rehabilitation (including transition care), geriatric management and other non-acute inpatient activity (Table 42).

Table 42: Actual and projected non-acute inpatient activity in the RHH

Year Change Bed type 2006–07 2011–12 2016 –17 No % Separations 1,120 2,728 3,503 2,383 213 % Bed days 28,289 44,826 56,994 28,705 101%

It should be noted that NSW Health no longer uses the acute activity modelling tool as the basis for planning sub-acute services.23 It is understood that this is because the tool is thought to over- estimate bed requirements. Nevertheless, it is clear that demand for sub-acute services will increase substantially as the population ages.

Detailed planning for sub-acute services including rehabilitation, geriatric evaluation and management, transition care and palliative care is continuing. The location of sub-acute services in relation to the new RHH is yet to be determined. It is recognised, however, that providing adequate facilities for these services will be critical to accommodating the needs of the referral population of the RHH into the future. As noted earlier in this report, the Department will publish an implementation plan for rehabilitation services by February 2009.

Modelled demand increases are being taken into account in planning for the new RHH. As well as incorporating additional facilities to accommodate predicted growth, the new RHH will be designed for highly efficient service delivery, including the following facilities and services: • An integrated cancer care service providing a comprehensive range of services covering consultation, treatment (including therapies such as chemotherapy, haematology and radiation oncology) and ongoing care (including palliative care information and counselling), as well as cancer surgery. • A comprehensive range of surgery, both as inpatient (day only or overnight) and outpatient services. One of the major strategies for delivering responsive surgery services will be the use of surgical short-stay units and a 23-hour care suite, as the majority of surgical care can be undertaken within a 24-hour period in a non-ward environment. • The statewide cardiothoracic surgical service will continue to be based at the new RHH. The Department, in consultation with the RHH and with cardiology services in Tasmania’s North, will consider strategies for potential flow reversal from interstate to the new RHH to enhance future service volumes. • Interventional services provide diagnostic, interventional, procedural and surgical services. This service will form a major suite in the new RHH, with access via the hospital for acute and emergency interventions and via the Hobart ICC for booked and elective interventions, including same day surgery.

23 NSW Health Statewide Services Development Branch Planning Series. Activity Planning Guideline for Subacute Inpatient Care Services. December 2006. p3.

Clinical Services Plan: Update 79 • The RHH provides a statewide burns service for adults. The burns clinic will be located in the new RHH. Major and complex burns cases will continue to be referred interstate for specialised treatment. Children with major burns are currently referred interstate for care and treatment and these arrangements will also continue with the new RHH. • Renal dialysis services for patients in Tasmania’s South include an acute unit at the main campus of the RHH, a non-acute satellite service at St John’s Park for patients establishing dialysis or who are in need of further supervision and management, and additional home dialysis. The acute dialysis service will continue at the new RHH, in both inpatient and acute ambulatory locations. It is proposed to continue providing non-acute dialysis from chairs in the St John’s Park site, as well as examining in the future the option of providing more satellite chairs at proposed Tier 3 ICCs. • The RHH is the State referral hospital for women’s and children’s services (WACS). WACS delivers comprehensive services to women and children in inpatient, outpatient and community settings, including maternity, neonatology, paediatric and gynaecology services. The new RHH will continue this role and level of service for WACS. • The acute mental health inpatient service in the new RHH will provide comprehensive care and treatment of adult and adolescent patients in a collocated service. There will be 46 inpatient beds, including an adult unit; a statewide psychiatric intensive care unit (PICU); a statewide adolescent mental health unit; and a psychiatric emergency care zone in the emergency department. • Medical imaging at the new RHH will be expanded to include a PET scanner. The Australian Government has committed $3.5 million in support of a PET scanner at the RHH. A business case for the PET is to be reviewed as the 2008–09 State Budget is developed. • Medi-hotels provide alternative patient accommodation for people who need to be close to nursing or medical support but do not require direct nursing supervision. A 15-bed medi-hotel is included within the scope of the New Royal Project. • The Hobart ICC will focus on the delivery of both acute and complex chronic health services to an ambulatory client group that may need access to tertiary hospital backup and support. The focus will be on day-only episodes of care. The ICC will have three key functions: – to be the portal for elective, non-urgent day surgery and other procedures; – to deliver a wide range of ambulatory care services, including diagnostic services; and – to provide specific services for people with chronic and complex co-morbid conditions, including cancer, diabetes/renal, cardio-respiratory and gastroenterology. • Demand for all non-acute inpatient services is projected to increase dramatically over the next 15 years. The most significant growth will be seen in rehabilitation (including transition care), geriatric management and other non-acute inpatient activity. • Non-acute aged care and rehabilitation services will remain integrated, both physically and operationally, but these services will not be brought onto the main campus of the new RHH. There is a clear opportunity with the New Royal Project to consider new site/s for what will need to be greatly expanded services. • Decisions on the optimum configuration and location of alcohol and other drug services in Hobart, including the preferred location of the detoxification service and pharmacotherapy program, will await the outcome of the current Alcohol, Tobacco and Other Drug Treatment Services Review. The review also will canvass the optimum range of in-reach services to be provided to new RHH.

80 Clinical Services Plan: Update Enablers of a sustainable service system

The 2007 Clinical Services Plan proposes a number of enablers of a sustainable service system including the development of a stable and skilled workforce; a number of teaching and research strategies; the formation of a Clinical Advisory Council; the development of clinical networks; the development of a statewide system for credentialling and approving the introduction of new technology; the development of more effective patient transport systems; and the provision of more accommodation options for patients and their families and carers.

These initiatives continue to be a priority, to support the implementation of the 2007 Clinical Services Plan.

Clinical networks Clinical networks, which have been developed in many health care systems nationally and internationally, are formal groups of clinicians who work together across organisational boundaries to improve the performance of the health care system. They provide a valuable platform for service planning, communication, system-wide coordination and improving quality in complex clinical service systems. They foster clinician cooperation and engagement in the health care system and create a vehicle for service development.

The 2007 Clinical Services Plan proposes the development of clinical networks in adult medical services; adult surgical services; aged care and rehabilitation; cancer services; cardiology/cardiac surgery; diabetes and chronic disease; emergency, critical care and trauma services; renal medicine; and women’s and children’s services incorporating maternal and perinatal services and paediatric medicine and surgery. It proposes that there be a clinical chair/leader of each clinical network and each network will: • be multidisciplinary; • meet regularly and develop and work in accordance with an agreed work plan; and • be provided with project officer support by the Department. The clinical networks will be led and coordinated by the Clinical Advisory Council, which will be the principal vehicle of advice to the Department about the structure and performance of the health care system. An interim Clinical Advisory Council has been convened.

Some concerns were raised during consultation for this Clinical Services Plan update that: • the role, terms of reference and management authority of the clinical networks are unclear; • clinical network leadership should reflect the needs and interests of all regions. Meeting the necessary commitments of a clinical network leader will be more achievable for clinicians who are employed on a full-time basis in the hospital system because those clinicians have specific time allocations for non- clinical duties. The majority of full-time medical practitioners in Tasmania are employed at the RHH, resulting in a concern that medical leadership of the clinical networks will be ‘Hobart-centric’; • the allocation of clinical disciplines and streams to each clinical network requires review and further consultation; • the administrative burden of supporting a large number of clinical networks in a small health care system may be excessive; and • the clinical groupings proposed for the clinical networks may not be the most appropriate.

Clinical Services Plan: Update 81 The engagement of clinicians in service development needs to continue. In Tasmania’s small health care system, clinical networking may take different forms, depending on the size and level of support required for a particular specialty area. Clinical networks often are engaged in the development of guidelines for clinical care; monitoring performance and advising on how it may be enhanced; and advising on policy development and planning. They usually do not have operational responsibility or management authority, however, and it will be important to ensure that the terms of reference of the clinical networks and the Clinical Advisory Council do not create confusion with respect to the operational responsibility of the hospital chief executive officers to implement agreed planning outcomes and ensure the delivery of quality services.

While it will be a fundamental responsibility for network leaders to recognise their statewide responsibilities and not adopt an organisation-specific orientation, the Department agrees that the network leadership group should incorporate clinicians from all areas of the State.

The cancer network is established and the Department has committed to developing a rehabilitation and aged care network by August 2008. Consistent with the priority health care needs of the Tasmanian community, a chronic disease network, which will have a strong focus on diabetes services, will be established before the end of 2008.

If the opportunity for Tasmanian clinicians to join an interstate network arises, it should be considered seriously. Participating in a clinical network with greater critical mass and the potential to access a larger pool of networking resources could be very beneficial to Tasmanian clinicians.

Implementation commitment 24 The Department will: • develop, by July 2008, a short consultation paper defining the role and draft terms of reference of the Clinical Advisory Council and presenting more detail about the proposed number and type of clinical networks to be established; the roles and responsibilities of network members; methods of supporting networks; and principles for network operation; • select the membership of and convene the Clinical Advisory Council by October 2008; • establish a rehabilitation and aged care network by August 2008 and a chronic disease network by December 2008; • ensure that fair and transparent arrangements are in place to fund and otherwise facilitate the provision of adequate back-up and clinical support for clinicians who assume leadership positions, particularly those who are not full-time employees in the public acute hospital system; • convene cardiac and renal forums by December 2009. These forums will be presented with data and opinion about current and future service delivery challenges and opportunities and consensus will be sought about the most appropriate method to facilitate ongoing clinical interaction across the State. Convening regular planning forums may be an alternative to establishing ongoing clinical networks for these sub-specialty services; and • convene, commencing by July 2009, statewide clinical consultative meetings twice yearly in each of women’s and children’s services; adult surgery; adult medicine; and critical care, trauma, emergency and retrieval services until formal ongoing networking structures have been agreed on and implemented.

82 Clinical Services Plan: Update Workforce The availability of a competent workforce in sufficient numbers and distributed according to service delivery needs will be critical to the development and success of Tasmania’s health care system.

There is a national and international shortage of health care professionals.

The 2007 Clinical Services Plan makes a number of commitments in the areas of education, training, recruitment and retention, designed to strengthen Tasmania’s health care workforce.

Implementation commitment 25 The Department will continue to work with the University of Tasmania and the tertiary and further education sector to develop and implement a long-term strategic plan that links Tasmania’s health care education and workforce needs. The strategic plan will link with this Clinical Services Plan update. In particular, the Department will undertake a workforce modelling exercise, based on the activity projections in this Clinical Services Plan update, to establish clear targets for workforce numbers in each health care professional category over the life of the Clinical Services Plan and identify key workforce risks and/or the need to redesign care pathways. The workforce plan will be developed by December 2009.

Stakeholder engagement and distributed governance Tasmania’s health care system will continue to strive to meet the increasing health care needs of an ageing population with a high prevalence of chronic disease. Preferential investment by all levels of government and the community in the maintenance of good health and prevention of illness, as well as reconfiguring the system to support more sustainable service delivery, will alleviate some pressures. Ultimately all health care systems have finite budgets within which they must operate, requiring decisions to be made about where and how resources should be applied to achieve the best value from public expenditure and the best health outcomes for the community.

Such decisions can be challenging. Inevitably, there are competing demands and opportunities.

The challenges that confront the health care system are not just challenges for the Minister or the Department and there is a critical need to engage a broad group of stakeholders in their resolution. All stakeholders including hospital managers, health care professionals, acute hospital patients and the broader community have an interest in (and ability to contribute to) effective decision-making about how and where scarce health care resources should be invested to best meet the needs of the community. Engagement of clinicians is a critical prerequisite to ensure that relevant clinical implications are taken account of in all significant decisions.

The Tasmanian health care system has been characterised in the past by a ‘top down’ governance approach which has tended to centralise decision-making within the Department. In the future, a more distributed system of governance will be adopted, so that more decisions can be made locally, with full engagement of the clinicians who are responsible for patient care, according to local needs and priorities.

Distributed governance requires clinicians and managers who assume local decision-making authority to assume corresponding accountability for working within agreed budgets and in accordance with agreed system-wide policies and strategies.

Clinical Services Plan: Update 83 The Department’s commitment to undertaking a review to ensure that funding allocations between Tasmania’s public acute hospitals are equitable and transparent (see Implementation commitment 19 on page 56) will support greater delegation of decision-making authority and accountability. Building on this base, performance agreements with hospital chief executive officers will define: • expectations of organisational performance including clinical activity to be achieved within agreed budget allocations; and • a requirement that they document and regularly report on progress towards achieving a clinical engagement strategy.

At a system-wide level, clinicians and other stakeholders will be engaged in decision-making through a variety of structures and processes including the clinical networks and the Clinical Advisory Council. A number of the structural changes detailed in this Plan (see discussion commencing on page 30) will enable greater stakeholder input into decision-making. The Department opened a regional office in Launceston recently and also intends to develop specific advisory structures to strengthen regional governance in the North and North West.

Ministerial community forums to discuss implementation of Tasmania’s Health Plan have enabled community input and will continue.

These engagement strategies reflect the need for priorities to be set in the overall community interest and the fact that better decisions will be made if the professionals who deliver health care services to our community also are engaged in planning those services and accounting to the community for the health care system’s performance.

Implementation commitment 26 The Department will work with the chief executive officers of each public acute hospital to define explicit performance agreements incorporating targets for clinical activity within agreed budgets and a requirement that they document a clinical engagement strategy and monitor and report on its effectiveness over time. Clinical engagement strategies will be developed by December 2008.

84 Clinical Services Plan: Update Glossary of abbreviations

ABS Australian Bureau of Statistics ACSC Ambulatory Care Sensitive Conditions ACT Australian Capital Territory AIHW Australian Institute of Health and Welfare ALOS Average Length of Stay BMT Bone Marrow Transplantation CACP Community Aged Care Packages CT Scanner Computed Tompgrahy Scanner DoHA Department of Health and Ageing (Commonwealth) the Department Department of Health and Human Services (Tasmania) ABS Australian Bureau of Statistics DRGs Diagnosis Related Groups ENT Ear, Nose and Throat ED Emergency Department ERP Estimated Resident Population GEM Geriatric Evaluation and Management GP General Practitioner HBOT Hyperbaric Oxygen Therapy ICC Integrated Care Centre ICU Intensive Care Unit Linac Linear Accelerator LGA Local Government Area LGH Launceston General Hospital MCRG Major Clinical Related Group MRI Magnetic Resonance Imaging MSAC Committee Medical Services Advisory Committee NHT Nursing Home Type NICU Neonatal Intensive Care Unit NSW New South Wales NT Northern Territory NW North West NWRH North West Regional Hospital PET Positron Emission Tomography PICU Psychiatric Intensive Care Unit QLD Queensland RACP Residential Aged Care Places RHH Royal Hobart Hospital SA South Australia SCN Special Care Nursery SEIFA Socio-Economic Indexes for Areas SLA Statistical Local Area TAS Tasmania TCGS Tasmanian Clinical Genetics Service VIC Victoria WA Western Australia

Clinical Services Plan: Update 85 Glossary of terms

Admitted patient A patient who undergoes a hospital’s formal admission process to receive (or inpatient) treatment and/or care. This treatment and/or care is provided over a period of time and can occur in hospital and/or in the person’s home (for hospital-in-the-home patients). Ambulatory care Hospitalisations that are thought to be avoidable if timely and adequate sensitive conditions non-hospital care, such as GP or primary care, is provided. Also referred to as avoidable hospitalisations. Average length The average number of patient days for admitted patient episodes. of stay Patients admitted and separated on the same day are allocated a length of stay of one day. Casemix adjusted A patient separation (see below) which has been adjusted using AR-DRG separation cost weights for the relative complexity of the patient’s clinical condition and for the hospital services provided. Collocated (Services) physically placed near one another, especially side by side. Overnight Overnight and multi-day stays. Paediatric Refers to children generally aged 14 years or under. Patient episode The period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type. Separation An episode of care for an admitted patient, which can be a total hospital stay (from admission to discharge, transfer or death), or a portion of a hospital stay beginning or ending in a change of type of care (for example, from acute to rehabilitation). Separation also means the process by which an admitted patient completes an episode of care either by being discharged, dying, transferring to another hospital or changing type of care.

86 Clinical Services Plan: Update Clinical Services Plan: Update 87 88 Clinical Services Plan: Update 0

Tasmania’s Health Plan

Clinical Services Plan: Update Incorporating changes to ownership of the Mersey Community Hospital May 2008

For more information on Tasmania’s Health Plan visit www.health.tas.gov.au Department of Health and Human Services