General Practice and Primary Care - Theses
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ItemFostering health: an Australian health policy and systems study of health assessment for children and young people in out-of-home care( 2014)This thesis reports on the first multi-centre health policy and systems study of the complex problem of health assessment for children and young people in Out-of-Home Care (OOHC) in Australia. The study has been conducted within a context of poor uptake of routine health assessment recommended by medical colleges. Analysis of the research literature around OOHC in Australia revealed that the implementation of routine health assessment had not been investigated in any systematic way. A national symposium held as part of this study confirmed the knowledge gap and identified a community of interest who supported research in this area. RESEARCH AIM: The study aimed to identify systemic and policy factors which enabled or inhibited the work of health professionals in health assessment for children in OOHC. METHODOLOGY: Guided by soft systems methodology I developed a series of conceptual models in which I imagined the elements of systems for each key step of care and then used these models as tools for comparison with experiences in the social or real world. Each of the models was built on a discrete theoretical purpose related to health assessment. The five purposes were to: I. Collect and maintain child health histories; II. Provide initial or preliminary health assessments at entry to OOHC; III. Provide comprehensive health assessments; IV. Develop individual child health management plans; V. Monitor the provision of assessment and treatment services and child health outcomes. In order to explore experiences in the social world, I undertook an embedded case-study to collect data from 9 organisations (incorporating 12 geographical sites) across two states of Australia with large OOHC populations. Case study data comprised my analysis of policy and procedural documents from state jurisdictions and local sites, observations from site visits and analysis of recordings from 47 semi-structured interviews with health professionals and policy advisors spanning 10 disciplines. RESULTS: The outcomes demonstrated that a lack of agreement about central concepts, such as how health is defined hampered consistency of assessment processes. Similarly I uncovered disparate ideas about the purpose of health assessment in OOHC, underpinned to some extent, by variable appreciation of child abuse and neglect as health determinants. At a systemic level, I found a synergy between conceptual models of systems of care associated with health assessment and the steps which health professionals both value and strive to implement in everyday practice. The results provide a compelling illustration of systemic complexity and interconnectedness. Across all steps of care the study results show that much hinges on the efficacy and effectiveness of the first step of collecting and sharing child health histories. In this step health professionals find themselves in a dependent relationship with staff from the child protection sector whose roles include gate-keeper, referrer, family liaison officer, child case manager and corporate parent. This dependence exemplifies a recurring theme in the everyday experiences of health professionals: the contrast between usual processes of patient care and the greater complexity of health assessment steps in OOHC. I argue for rethinking health policies which have been premised on minimalist approaches involving either usual, universal health care or “tweaking” usual health care processes. Minimalist interventions, such as giving children in OOHC priority in the queue for assessment cannot by themselves bring about the extent of systemic changes desired by health professionals. Of critical need are permanent and accessible health records for children who have experienced maltreatment. This thesis demonstrated that the health policy and system approach has broad utility in improving our understanding of what has been problematic about health assessment in OOHC in Australia and what changes are desirable in assessment approaches. A key strength of the study was that multi-centre and multi-disciplinary recruitment across two legislative jurisdictions enabled me to capture health professionals’ views and experiences from multiple contexts. This added richness to the data and rigour to the generalizability of the study results. IMPLICATIONS: As a result of this study I formed a view that professional purposes, judgement and volition among health professionals are individual matters, more influenced by peers, training and clinical experience than by public policy. Not only do doctors have a unique role to play in clinical governance in OOHC but their knowledge and skills, their professional roles and identity and their beliefs about the consequences of their work are important influences in bringing about quality improvement in health care. Messages from research and the recommendations of medical colleges in Australia, U.S. and U.K. were clear that health professionals believed individualized, systematic health assessment was warranted in OOHC, notwithstanding the cost. Furthermore, doctors in this study demonstrated sufficient power and professional autonomy to stop, start, block, enhance or lead initiatives to improve health assessment in OOHC. Analysis of the steps of care associated with health assessment in OOHC revealed a deeply complex web of inter-connected activities which rest on sophisticated clinical decision making by doctors. The results of this thesis indicate that health professionals are aided in their work when governments and child protection agencies appreciate this complexity and sophistication. The results of this study suggest areas where change is desirable in order to break the impasse of poor implementation of health assessment. A more congruent common understanding of the concept of health in OOHC is essential i.e. what is being assessed. Alongside this a more careful alignment of theoretical and practical purposes in health assessment is needed. I argue that in the context of Australia’s moral and civic obligations under the 1989 United Nations Convention on the Rights of the Child, purposes of health assessment must be more coherently aligned around reparative health care, and responsive to the impacts of child maltreatment on life-course health outcomes. More widespread appreciation of maltreatment as a health determinant is required in order for policy advisors and health practitioners to better align health assessment policies and practices.