5. Child Health Check Phase 2 (follow-up)
Phase 2 of the AG CHC initiative involves the follow up of medical and other conditions identified by the CHCs. Ethical practice demands such follow up should have been planned prior to commencement of the CHCs, however, this was not done properly. Instead, Phase 2 has been hastily organised on the run without proper resources and capacity being in place.
One consequence of this lack of planning has been that DoHA has been micro-managing the process simply in order to maintain a handle on it, resulting in frustrating delays, confusion and uncertainty. It has also led to the unnecessary duplication and over-complexity of the administration and service delivery.
Much of the frustration has centred around the unrealistic timeframes proposed for Phase 2. This in turn has resulted from the decision to situate the CHC initiative within the ambit of the emergency response and thus be subject to its timeframes and funding requirements. It was originally planned that Phase 2 would be completed by June 30 2008. Three months out from this date Phase 2 work had not even begun, yet the Commonwealth was pressuring health services to put in submissions for funding, recruit staff and complete complex work programs by June 30 – an impossible and daunting task, particularly for remote health services. Primary health care services were given only two weeks to submit their plans.28 Some health services declined to do so on the basis that it was an impossible expectation and entailed the added possibility that the health service might be blamed for any failure and might therefore be subject to an adverse risk assessment. Those health services that did take on Phase 2 had to take this risk and also to accept verbal assurances (because written assurances were refused) that funding would be rolled over past June 30. As mentioned earlier, the best outcome was achieved where health services were able to do Phase 1 and 2 concurrently with no significant delays between diagnosis and primary health care follow up.
At the time of writing Phase 2 is far from complete, with the vast majority of the specialist follow-up yet to be done. Never-the-less, a new cut-off date of September 30 has been set despite the fact that the specialist follow-up cannot possibly be completed by this date. It may be that specialist follow up will be allowed to continue beyond this date but this is not clear to AMSANT as yet. Once again health services are being left in the dark as to how this will affect the process and funding for completing the follow-up of the Phase 1 CHCs.
Despite survey reports confirming limited clinical space and staff accommodation, services have had difficulty convincing NTECC of their lack of infrastructure to support the initiative within the short timeframes of Phase 2. This has resulted in protracted negotiation before additional funding for infrastructure was approved for services. Most services won't have infrastructure in place before Phase 2 is scheduled to end on the 30th September.
Some member services have reported being able to acquire useful infrastructure for their Phase 2 activities, such as medical and IT equipment, a hearing booth, tympanograms and other equipment, which will continue to benefit services beyond Phase 2.
In an attempt to address the service delivery gap in completing the Phase 2 work within the (re)scheduled timeframe, NTECC has suggested that some of the Phase 3 funding for the Expanding Health Service Delivery Initiative (EHSDI) be used for the completion of the CHC follow-up.
Further problems relate to the data collection from Phase 1 upon which the follow-up and specialist referral of health problems identified by the CHCs is based. The decision not to use the standard Medicare form for the CHCs has created numerous technical and ethical issues around the collection, sharing and analysis of the data. For example, privacy considerations have prevented the timely return of data gathered from the CHCs to communities and health services despite this being promised by NTECC prior to the health checks being carried out. We understand that community level feedback is to be provided and we welcome this although there would be more value to this exercise if it also involved plans for how to improve the response to child health as part of the EHSDI.
Problems have also been experienced with the populated Chart Review Forms used to return data in a de-identified form on children requiring follow-up treatment. Frequent errors in transcribing data onto the forms have created difficulties for health services in matching the data back to the actual patient it refers to and services have had to engage or divert appropriately skilled personnel to complete the forms.
Another problem area has been the referral system itself. Although there is a functioning referral process in the Central Australia, NTECC did not ensure that there were appropriate referral processes for the Top End, where three quarters of the NT's Aboriginal children reside. Confusion also exists around the status of children already on waiting lists prior to the Phase 1 health checks. NT DHF, which has taken over the coordination of the Phase 2 follow-up, has been slow to respond to and rectify these problems.
DHF have been unable to provide schedules for the roll-out of specialist follow-up for AMSANT member services. Top End schedules for ENT and dental follow-up show that the limited services available are mostly being provided to DHF clinics and that almost no follow-up is planned for Top End AMSs during 2008.
Conversely, in Central Australia, some services have been assigned unnecessary specialist follow-up. In one community where only one child required ear surgery, DoHA has scheduled a further ear check of children that is not needed. At the same time, other problems that need prompt follow-up, such as a recent outbreak of petrol sniffing, have not yet been responded to.
Specialist surgeons who have been involved in the Phase 2 work have provided feedback that the process was poorly organised and resulted in a considerable amount of their time being wasted. They felt that, on balance, the money would have been better spent on primary health care.
The kinds of problems being experienced with the Phase 2 follow-up are symptomatic of the error of applying short-term planning and solutions to health issues that should be addressed through properly-resourced on-going primary health care. It also creates the additional problem of having to refocus efforts back onto providing sustainable, long-term primary health care systems and services once the short-term measure is finished.
AMSANT urges the Review panel to recommend that the Australian Government commits to extending the timeframe and funding for Phase 2 primary health care, specialist and hospital follow up to ensure that all follow-up work is completed, and to provide clear advice to health services on the matter. [See Recommendation 6]
28. In comparison, OATSIH took 6 months to plan Phase 2.