Challenges in health services and health systems research

The relationship between emerging trends in healthcare systems and the consequent research priorities will be explored.

Governments and policy makers in developed countries are increasingly focused on the management of chronic disease, reflecting demographic changes and shifts in the burden of disease. Systems of quality improvement and reward are increasingly based on performance in chronic disease management. There is some evidence that countries with well-developed systems of primary care, such as Australia, achieve better health outcomes at less cost. In the past 15 years, almost all developed countries have undergone some type of health care reform. There has been a major focus on reducing costs; often involving shifting services from secondary to primary care. While there are few international comparisons, most suggest a complex relationship between the strength of primary care within the overall health services system and good performance, particularly with regard to lower costs of care and particularly relevant measures of health.

Aims for 21st century health systems
What, then, are the issues which are shaping contemporary general practice in developed countries? There are several imperatives: Safety, effectiveness, patient-centredness, timeliness, efficiency and equity. A study by the Nuffield Trust (Dargie, 1999) projected the shape of healthcare for the first fifteen years of this century. The study identified six issues that need to be addressed in the process of formulating health systems policies:

• Peoples’ expectations and financial sustainability
• Demography and ageing
• Information and knowledge management
• Scientific advance and new technology
• Workforce education and training
• Systems performance and quality (efficiency, effectiveness, economy
and equity)

Each of these six issues requires innovative thinking and priority setting on the part of the health sector, such as the delivery of health services in new and creative ways. Furthermore, there is a clear need for a finely tuned research, development and evaluation strategies to match these goals.

Accounting services and SMEs : an Australian study

Background: The observance of regulation has become a fundamental part of life for the conduct of business around the world. Governments and their duly appointed designates, acting in the interest of the collective public, have relied on regulation to moderate economic and social behaviour through the imposition and enforcement of rules. While it can be commonly accepted that such a prescriptive framework may be necessary for the achievement of desired economic and social outcomes, regulation does impose costs on society and on individual firms. These costs, which can include the costs for government departments to administer, the cost for firms to comply, and the multitude of indirect costs such as lost innovation and productivity or their interrelated opportunity costs, have received ample attention.

Accountants are key advisers to all businesses on all aspects of doing business, including regulation. As such, it is appropriate that ACCA has sponsored this study, which explores the regulatory issues facing SMEs and the critical role that accountants and other organisations play in helping SMEs be aware of, comply with and generally manage effectively the regulations that apply to their business.

ACCA has consistently argued for a balanced view to be taken on regulation, recognising that certain rules are necessary for the fair development of business and for employees’ rights. Yet at the same time, ACCA recognises that SMEs are likely to be disproportionately burdened by regulatory requirements and, as a consequence, it actively campaigns for fairness in regulation, recognising the issue as a significant factor in the success, productivity and growth of small businesses.

Overview: This study complements similar research commissioned by ACCA in the United Kingdom and Canada (Blackburn et al. 2006), with the aim of helping to provide a more international picture of the effects of regulation on adviceseeking by SMEs and how accountants can help SMEs meet their regulatory obligations.

The research commenced in November 2006 and was conducted over the Australian summer period 2006/7, among SMEs and accounting practices, as follows:

* telephone survey among 250 SMEs
* postal survey among 130 accounting practitioner firms.

Key findings: The SME section of this study revealed the following points.

* Most SMEs (between 70% and 80%), agreed that the regulations under review were reasonable, however there were significantly high levels of concern regarding:
* the number of regulations affecting their business (80%)
* staying up to date with changing regulations (80%)
* complexity of regulation or the ease of understanding regulations (77%)
* inequity, or the cost of regulation in proportion to the business (66%)
* duplication, or being required to provide the same information to more than one government department (55%).
* External accountants were the most common source of advice, being used by 72% of SMEs; this was followed by federal government agencies,    62%; trade or industry bodies, 61%; and a lawyer or solicitor, 53%.
* Highest levels of satisfaction with the advice provided were recorded for lawyers/solicitors (94%), banks (91%) and external accountants (90%).
* Overall, 80% of SMEs who had used accountants rated their service as excellent or good. Thirty per cent gave accountants an excellent rating.
* Accountants rated particularly well on the following attributes:
* the potential for a long-term relationship with the business (81% excellent/good)
* technical understanding of the regulatory requirements that apply to the business (79%)
* ability to meet the needs of the business (77%)
* understanding of the business of the SME and its operations (73%).

The survey of accounting practitioners produced the following information.
* The results indicate that SME firms with fewer than 10 employees are the main source of revenue for the respondent accounting practitioners.
* Virtually all accountants provide regulatory advice, primarily in the areas of taxation (particularly Goods and Services Tax, GST), and Do-It-      Yourself (DIY) superannuation requirements. These services provided the accountants with their largest business growth in the two years before the time of the survey.

Seventy-nine per cent of accountants referred their SME clients to external professional advisers. Their comments indicate (see Appendix 4) that some accountants consider their role to be as convenors or advisers for their SME clients. Importantly, according to the accountants, SME firms with fewer than 10 employees did not update their knowledge of regulatory requirements; they relied on their accountant for the right advice. The main types of external adviser to whom accountants referred their SME clients were lawyers and financial planners.

* Accountants expressed their concern regarding the complexity and amount of regulations affecting their SME clients.
* The accountants also stated that they would like to provide additional advice to their SME clients.
 
Confidence intervals – SME survey:  The survey sample size was 250 SMEs from the total of 1.2 million Australian SMEs. Any estimate of proportions agreeing or disagreeing with particular statements must be considered with respect to the margin of possible statistical error. Owing to the small sample size, generalising the results from this study to a wider population of SMEs may be constrained.

A 95% confidence interval of the sample mean for the following estimates based on a percentage agreement of 75% to a proposition with a sample size of 250 would be from 69.5% to 80.5%. The 95% confidence interval for estimates of any other value will diverge slightly in magnitude from the numbers given.

In general then we can be highly confident that the actual sample mean will be within approximately ± 5% of the figure given, with a survey of this size. Confidence intervals – acounting practitioner survey IBISWorld estimates reveal a figure of 9,222 accounting practices in Australia as at June 2006 (IBISWorld 2007). The sample size of 133 accounting practitioners gives a 95% confidence limit that the results reported from the mail-out survey are within the ± 5% confidence interval of the reported values.

Conclusions:  This report describes the results of two parallel surveys undertaken on the impact of business regulation on small and medium-sized enterprises in Australia and on the perceptions of accounting firms about the ways in which the regulatory impact on the SME sector drove their business.

The survey of SMEs provides empirical support for many of the concerns raised with the Regulation Taskforce, which reported to the Australian government in 2006. Many businesses are concerned about the volume and complexity of government legislation as it applies to their business. They are concerned that they are unable to keep up with new legislation and that there is apparent duplication of reporting requirements across the various tiers of government.

The survey of accountants revealed that accounting firms derive a significant proportion of their revenue from SMEs. While the SMEs are concerned with regulatory changes, the accountants surveyed reported that the major growth areas in their businesses were in what could be seen as traditional accounting areas of tax and superannuation. Some SMEs sought advice on areas such as employment law, environmental regulation and health and safety but it appears that many accountants refer their clients to specialists in these areas. Recent changes to the laws regarding financial planning in Australia may lead to changes in the market for financial advice in Australia, with many accountants apparently regarding this as a key driver of future business opportunities.

The surveys were conducted using a similar instrument to similar surveys conducted in the UK and Canada and reported in Blackburn et al. (2006). Comparisons of the Australian survey results with those from the UK and Canada seem to support the perception that Australian business is not over-regulated, but the SME sector is concerned with the volume and complexity of regulation. This suggests that the SME sector wants to see improvements to Australia’s regulatory regime as a result of the work of the Regulation Taskforce undertaken in 2005/6. In its response to the work of the Taskforce the government agreed with 158 of the 178 specific recommendations of the Taskforce. This now needs to be followed through at all levels of government.

Accountants in all three countries understand their SME clients’ concerns with the burden of regulation and they are prepared to advise their clients where appropriate or refer them to specialist advisers. Most business growth for accountants has come from the taxation area. Very few accountants in the UK or Australia specialise in providing advice in the areas of environmental regulation or health and safety regulation.

International comparisons show that in all three countries accountants are generally highly regarded by SMEs for their professionalism and competence. The major area of client concern is the value for money offered by the accountant’s service. In an era of rapidly shifting professional and technical boundaries, accountants need to be more strongly attuned to levels of client satisfaction. Lawyers, financial planners and a plethora of specialist advisers operate in the business services market and if they have an opportunity to take business from accountants by competing on price they may well do so. This suggests a stronger role for professional accounting bodies in monitoring the broader business services market for opportunities and threats on behalf of their membership.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background : Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods : Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results : Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion : Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

Evaluation of heat stress indices using physiological comparisons in an alumina refinery in a sub-tropical climate

The production of alumina involves the use of a process known as the Bayer process. This method involves the digestion of raw bauxite in sodium hydroxide at temperatures around 250°C. The resultant pregnant liquor then goes through a number of filtering and precipitation processes to obtain the aluminium oxide crystals which are then calcined to obtain the final product. The plant is situated in a sub tropical climate in Northern Australia and this combined with the hot nature of the process results in a potential for heat related illnesses to develop. When assessing a work environment for heat stress a heat stress index is often employed as a guideline and to date the Wet Bulb Globe Temperature (WBGT) has been the recommended index. There have been concerns over the past that the WBGT is not suited to the Northern Australian climate and in fact studies in other countries have suggested this is the case. This study was undertaken in the alumina plant situated in Gladstone Queensland to assess if WBGT was in fact the most suitable index for use or if another was more applicable. To this end three indices, Wet Bulb Globe Temperature (WBGT), Heat Stress Index (HSI) and Required Sweat Rate (SWreq) were compared and assessed using physiological monitoring of heart rate and surrogate core temperature. A number of different jobs and locations around the plant were investigated utilising personal and environmental monitoring equipment. These results were then collated and analysed using a computer program written as part of the study for the manipulation of the environmental data . Physiological assessment was carried out using methods approved by international bodies such as National Institute for Occupational Safety & Health (NIOSH) and International Standards Organisation (ISO) and incorporated the use of a ‘Physiological Factor’ developed to enable the comparison of predicted allowable exposure times and strain on the individual. Results indicated that of the three indices tested, Required Sweat Rate was found to be the most suitable for the climate and in the environment of interest. The WBGT system was suitable in areas in the moderate temperature range (ie 28 to 32°C) but had some deficiencies above this temperature or where the relative humidity exceeded approximately 80%. It was however suitable as a first estimate or first line indicator. HSI over-estimated the physiological strain in situations of high temperatures, low air flows and exaggerated the benefit of artificial air flows on the worker in certain environments ie. fans.

Assessing the Cost Effectiveness of obesity interventions - the ACE model

A workshop presentation

The demography of investor heaven : a synthesis of international research on the characteristics, attitudes, and investment behaviour of business angels

The purpose of this paper was to compile and compare the findings of all robust international research providing national profiles of business angels (informal venture capitalists). At the outset, it was not clear how comparable studies would be and, as the project advanced, it became clear that few direct comparisons would be possible. Nevertheless, there were broad categories common to many studies and consequently a template was developed and used to summarise each study in a consistent format. The resulting report thus provides a summary of the data across 16 studies covering 9 different countries, with key points from the findings of each study.

This is by no means an elegant report, but the authors believe it is a useful one. It provides a compendium of international angel research neatly bundled in one package. It should benefit anyone considering conducting the first study of business angels for their country or building on research already completed.

Analysis of the cost performance of structural building frames in Australia

The significance of this research is that it is the first comprehensive analysis of cost performance across Australia. It is well known that measuring cost performance is not an easy task; comparisons of building projects on a `like-for-like’ basis are uncommon, and rarely occur in the real world. However, this paper analyses 120 different structural frame models that represent various; structural designs, construction methods, grid spans, and locations.

The research produced price models that were representative of structural frames used in medium-rise non-residential buildings. It is based on pricing a number of standard building frame designs in five Australian cities. The results represent the cost of producing the same building in different locations, using similar building construction techniques. By utilizing a standard model, project variables like building quality, ground conditions and access were eradicated, thereby facilitating an unbiased comparison of cost performance. I addition, the results are an indicator of building productivity based on costs per square metre of various construction types.

This research provides the Australian industry with robust data about the relative cost performance of various structural building frames. In addition, this research has wider implications because the models may also become useful data for the measuring relative cost performance in other countries.

The cost of housing : more than just dollars

Australians were recently awarded the dubious honour of building the largest homes in the world. Our new homes are now seven percent larger than those in the United States and nearly three times larger than those in the United Kingdom. At the same time, the price of an average residential property is now five times what it was 20 years ago. Although incomes have risen over the same period, they have not kept pace with rising house prices. In terms of disposable income, the cost of housing has almost doubled. While traditional housing affordability is measured in terms of house prices and incomes, a broader and more encompassing perspective also indicates that we can no longer ‘afford’ to build houses as we have done in the past. The environmental impact of modern Australian housing is significant. Australians have resisted the need for increased urban density as their capital city populations grow and new houses have been built on the outskirts of the existing cities, encroaching on the greenwedge and agricultural lands, destroying and degrading existing fauna and flora. The houses built have increased carbon emissions because of their size, embodied energy and reliance on the motor car. This paper discusses the environmental ‘affordability’ of current Australian housing and argues that this must be considered alongside traditional affordability criteria so that a more holistic approach to the issues is adopted.

Putting the Australian Labor Party in international perspective

This paper assesses the Australian Labor Party's current debates over future directions with reference to attempts by the left of centre political parties in other western nations, especially in Western Europe, to deal with the end of the economic "golden age" since the early 1970s and the widespread resurgence of neo-liberal ideologies since the late 1970s. The dominant recent view of such comparisons has been through the ideological lens of the "Third Way". This vision however tends not to see relevant variations between the experiences of social democratic parties in individual Western European nations as they have sought to deal with adverse circumstances since the early 1970s. Nor does the Third Way view sufficiently extend to the widely varying background landscapes: that is, the different levels of historical achievement by left of centre parties in the different nations. Some social democratic parties in European countries are pursuing more progressive political agendas than the British Labour Party under Tony Blair and they are starting from a very different basis of policy achievement and political strength than either the British or Australian labour parties. The nature and extent of these international differences need now to be highlighted from an Australian political perspective in order to better inform the current debate about the range of options for the ALP and the current comparative condition of the Australian party system. As part of this analysis, the relationship between the erosion of the traditional blue-collar support bases of the major left of centre parties in various nations, amid economic restructuring and challenges to traditional immigration patterns, and the rise of support for anti-immigrant policies and parties, need to be carefully examined and evaluated.

The human cost of fracture

In this population-based, observational study, we document the personal burden of fracture and utilization of community and health services for women during the 12-month period following a fracture. Participants were 598 women (aged 35-92 years) with incident fracture in the years 1994-1996 who were enrolled in the Geelong Osteoporosis Study. Almost all hip fracture cases and 27% of nonhip fracture cases were hospitalized. Homes were modified in 14% of cases, and 32% of the women purchased or hired equipment to assist with activities of daily living. Three-quarters of women with hip, pelvis, or lower limb fractures were confined to the home, had to walk with a walking aid, or could walk only short distances for several weeks. After a year, nearly one-half had not regained prefracture mobility. One-seventh of women with upper-limb fractures did not venture outside the home for at least 6 weeks. Nearly half of all fracture cases needed help with personal care and housework during the first 6 weeks. After 6 months, 3.4% of all patients and 19.6% of hip, 12.8% of humeral, and 4.7% of spine fracture patients required assistance with bathing and showering. After a year, more than half of the hip fracture cases remained restricted regarding housework, gardening, and transport. These findings have important implications for rehabilitation therapy. A fracture, regardless of site, had a major impact on a woman's lifestyle and well-being. Most women were restricted in their activities of daily living and suffered loss of confidence and independence. Short-term morbidity was common for all fractures, with varying degrees of prolonged morbidity often extending to at least a year postfracture.