Emergency Health Services (EHS) : demand and service delivery models. [Monograph 2 : Queensland EHS users’ profile]

Emergency health is a critical component of Australia’s health system and one which is increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the characteristics of users of emergency health services with an aim to identify those that appear to contribute to demand growth. This study utilises data on patients treated by Emergency Departments (ED) and Queensland Ambulance Service (QAS) across Queensland. ED data was derived from the Emergency Department Information System (EDIS) for the period 2001-02 through to 2010-11. Ambulance data was extracted from the QAS’ Ambulance Information Management System (AIMS) and electronic Ambulance Report Form (eARF) for the period 2001-02 through to 2009-10. Due to discrepancies and comparability issues for ED data, this monograph compares data from the 2003-04 time period with 2010-11 data for 21 of the reporting EDs. Also a snapshot of users for the 2010-11 financial year for 31 reporting EDs is used to describe the characteristics of users and to compare those characteristics with population demographics. For QAS data, the 2002-03 and 2009-10 time periods were selected for detailed analyses to identify trends. • Demand for emergency health care services is increasing, representing both increased population and increased relative utilisation. Per capita demand for ED attention has increased by 2% per annum over the last decade and for ambulance attention by 3.7% per annum. • The growth in ED demand is prominent in more urgent triage categories with actual decline in less urgent patients. An estimated 55% of patients attend hospital EDs outside of normal working hours. There is no evidence that patients presenting out of hours are significantly different to those presenting within working hours; they have similar triage assessments and outcomes. • Patients suffering from injuries and poisoning comprise 28% of the ED workload (an increase of 65% in the study period), whilst declines of 32% in cardiovascular and circulatory conditions, and musculoskeletal problems have been observed. • 25.6% of patients attending EDs are admitted to hospital. 19% of admitted patients and 7% of patients who die in the ED are triage category 4 or 5 on arrival. • The average age of ED patients is 35.6 years. Demand has grown in all age groups and amongst both men and women. Men have higher utilisation rates for ED in all age groups. The only group where the growth rate in women has exceeded men is in the 20-29 age group; this growth is particularly in the injury and poisoning categories. • Considerable attention has been paid publicly to ED performance criteria. It is worth noting that 50% of all patients were treated within 33 minutes of arrival. • Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people appears to exceed those of European and other backgrounds. The utilisation rates for immigrant people is generally less than that of Australian born however it has not been possible to eliminate the confounding impact of different age and socioeconomic profiles. • Demand for ambulance service is also increasing at a rate that exceeds population growth. Utilisation rates have increased by an average of 5% per annum in Queensland compared to 3.6% nationally, and the utilisation rate in Queensland is 27% higher than the national average. • The growth in ambulance utilisation has also been amongst the more urgent categories of dispatch and utilisation rates are higher in rural and regional areas than in the metropolitan area. The demand for ambulance increases with age but the growth in demand for ambulance service has been more prominent in younger age groups. These findings contribute significantly to an understanding of the growth in demand for emergency health. It shows that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that the congestion of emergency health services is due to inappropriate attendees is unable to be substantiated. The consistency of the growth in demand over the last decade reflects not only the changing demographics of the Australian population but also the changes in health status, standards of acute health care and other social factors. The growth is also amongst patients with acute injury and poisoning which is inconsistent with rates of chronic disease as a fundamental driver. We have also interviewed patients in regard to their decision making choices for acute health care and the factors that influence these decisions and this will be the subject of a third Monograph and publications.

A critical appraisal of responses to Maori offending

This article critically analyses the role that criminological theory and specific policy formulations of culture play in the New Zealand state’s response to the over-representation of Māori in the criminal justice system. Part one provides an overview of the changing criminological explanations of, and responses to, Māori offending in New Zealand from the 1980s onwards and how these understandings extended colonialist approaches to Māori and crime into the neo-colonial context. In particular, we chart the shift in policy development from theorising Māori offending as attributable to loss of cultural identity to a focus on socio-economic and institutional antecedents and, finally, through the risk factors, assessment, and criminogenic needs approaches that have gained prominence in the current policy context. In part two, the focus moves to the strategies employed by members of the academy to elevate their own epistemological constructions of Māori social reality within the policy development process. In particular, the critique scrutinises recent attempts to portray Indigenous responses to social harm as “unscientific” and, in part, responsible for the continuing over-representation of Māori in New Zealand’s criminal justice system. The purpose of this analysis is to focus the critical, criminological gaze firmly on the activities of policy makers and administrative criminologists, to examine how their policies and approaches impact on Māori as an Indigenous people.

Access to cardiac rehabilitation does not equate to attendance

Background/Aims Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia. Methods An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h). Results Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event. Conclusion Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

Access to Cardiac Rehabilitation does not Equate to Attendance. (On Behalf of the Cardiac ARIA Project. Winner Nursing/Allied Health Professional Investigator Award)

Background/Aims Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia. Methods An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h). Results Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event. Conclusion Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

Welfare reform, surveillance and new paternalism

This paper discusses the situation of welfare claimants, often constructed as faulty citizens and flawed welfare subjects. Many are on the receiving end of complex, multi-layered forms of surveillance aimed at securing socially responsible and compliant behaviours. In Australia, as in other Western countries, neoliberal economic regimes with their harsh and often repressive treatment of welfare recipients operate in tandem with a burgeoning and costly arsenal of CCTV and other surveillance and governance assemblages. The Australian Government’s Centrelink BasicsCard is but one example of welfare surveillance, whereby a percentage of a welfare claimant’s allowances must be spent on ‘approved’ items. The BasicsCard which has perhaps slipped under the radar of public discussion and is expanding nationally, raises significant questions about whether it is possible to encourage people to take responsibility for themselves if they no longer have real control over the most important aspects of their lives. Resistance and critical feedback, particularly from Indigenous people, points to a loss of dignity around the imposition of income management, operational complexity and denial of individual agency in using the BasicsCard, alongside the contradiction of apparently becoming ‘self-reliant’ through being income managed by the welfare state. This paper highlights the lack of solid evidence for the implementation/imposition of the BasicsCard and points to the importance of developing critically based research to inform the enactment of evidence based policy, also acting as a touchstone for governmental accountability. In highlighting issues around the BasicsCard this paper makes a contribution to the largely under discussed area of income management and the growth of welfare surveillance in Australia.

Study protocol : Screening and treatment of alcohol-related trauma (START): a randomised controlled trial

Background: The incidence of mandibular fractures in the Northern Territory of Australia is very high, especially among Indigenous people. Alcohol intoxication is implicated in the majority of facial injuries, and substance use is therefore an important target for secondary prevention. The current study tests the efficacy of a brief therapy, Motivational Care Planning, in improving wellbeing and substance misuse in youth and adults hospitalised with alcohol-related facial trauma. Methods and design: The study is a randomised controlled trial with 6 months of follow-up, to examine the effectiveness of a brief and culturally adapted intervention in improving outcomes for trauma patients with at-risk drinking admitted to the Royal Darwin Hospital maxillofacial surgery unit. Potential participants are identified using AUDIT-C questionnaire. Eligible participants are randomised to either Motivational Care Planning (MCP) or Treatment as Usual (TAU). The outcome measures will include quantity and frequency of alcohol and other substance use by Timeline Followback. The recruitment target is 154 participants, which with 20% dropout, is hoped to provide 124 people receiving treatment and follow-up. Discussion: This project introduces screening and brief interventions for high-risk drinkers admitted to the hospital with facial trauma. It introduces a practical approach to integrating brief interventions in the hospital setting, and has potential to demonstrate significant benefits for at-risk drinkers with facial trauma.

Successful outcomes in vocational education and training courses : how pedagogy and expectations influence achievement

This paper reports on a four year Australian Research Council funded Linkage Project titled Skilling Indigenous Queensland, conducted in regional areas of Queensland, Australia from 2009 to 2013. The project sought to investigate vocational education, training (VET) and teaching, Indigenous learners’ needs, employer cultural and expectations and community culture and expectations to identify best practice in numeracy teaching for Indigenous VET learners. Specifically it focused on ways to enhance the teaching and learning of courses and the associated mathematics in such courses to benefit learners and increase their future opportunities of employment. To date thirty-nine teachers/trainers/teacher aides and two hundred and thirty-one students consented to participate in the project. Nine VET courses were nominated to be the focus on the study. This paper focuses on questionnaire and interview responses from four trainers, two teacher aides and six students. In recent years a considerable amount of funding has been allocated to increasing Indigenous Peoples’ participation in education and employment. This increased funding is predicated on the assumption that it will make a difference and contribute to closing the education gap between Indigenous and non-Indigenous Australians (Council of Australia Governments, 2009). The central tenet is that access to education for Indigenous People will create substantial social and economic benefits for regional and remote Indigenous People. The project’s aim is to address some of the issues associated with the gap. To achieve the aims, the project adopted a mixed methods design aimed at benefitting research participants and included: participatory collaborative action research (Kemmis & McTaggart, 1988) and, community research (Smith, 1999). Participatory collaborative action research refers to a is a “collective, self-reflective enquiry undertaken by participants in social situations in order to improve the rationality and justice of their own social and educational practices” (Kemmis et al., 1988, p. 5). Community research is described as an approach that “conveys a much more intimate, human and self-defined space” (p. 127). Community research relies on and validates the community’s own definitions. As the project is informed by the social at a community level, it is described as “community action research or emancipatory research” (Smith, 1999, p. 127). It seeks to demonstrate benefit to the community, making positive differences in the lives of Indigenous People and communities. The data collection techniques included survey questionnaires, video recording of teaching and learning processes, teacher reflective video analysis of teaching, observations, semi-structured interviews and student numeracy testing. As a result of these processes, the findings indicate that VET course teachers work hard to adopt contextualising strategies to their teaching, however this process is not always straight forward because of the perceptions of how mathematics has been taught and learned historically. Further teachers, trainers and students have high expectations of one another with the view to successful outcomes from the courses.

International trends in early childhood education for sustainability

Early childhood education for sustainability (ECEfS) is an emerging field within education – a synthesis of early childhood education and education for sustainability. As a distinct field of educational inquiry and practice, it is less than 20 years old in Australia. My personal story is one that emerged from teaching Aboriginal children in an Indigenous community. These experiences made me question the marginalization of Indigenous peoples in Australian society, the colonizing impacts of education, gave me deeper understandings of human-environment interactions, and the effects of poverty and powerlessness on options for Indigenous people in Australia and elsewhere where people and their lands have been exploited. These experiences saw me return to university to undertake a degree in environmental studies to help me better understand the nexus between society, environment and economy. Hence my background in education for sustainability comes as much from the social sciences as from the biological/ecological sciences and shapes my orientation to my work in ECEFS...

The growing demand for emergency healthcare

Emergency health is a critical component of health systems; one increasingly congested from growing demand and blocked access to care. The Emergency Health Services Queensland (EHSQ) study aimed to identify the factors driving increased demand for emergency healthcare. This study examined data on patients treated by the ambulance service and Emergency Departments across Queensland. Data was derived from the Queensland Ambulance Service’s (QAS) Ambulance Information Management System and electronic Ambulance Report Form and from the Emergency Department Information System (EDIS). Data was obtained for the period 2001-02 through to 2009-10. A snapshot of users for the 2009-10 year was used to describe the characteristics of users and comparisons made with the year 2003-04 to identify trends. Per capita demand for EDs has increased by 2% per annum over the decade and for ambulance by 3.7% per annum. The growth in ED demand is most significant in more urgent triage categories with decline in less urgent patients. The growth is most prominent amongst patients suffering injuries and poisoning, amongst both men and women and across all age groups. Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people exceeds those of other backgrounds. The utilisation rates for immigrant people is less than Australian born however it has not been possible to eliminate the confounding impact of age and socioeconomic profiles. These findings contribute to an understanding of the growth in demand for emergency health. It is evident that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that congested emergency health services is due to inappropriate attendees is unsustainable. The growth in demand over the last decade reflects not only on changing demographics of the Australian population but also changes in health status, standards of acute health care and other social factors.

The ethical demands of settler colonial theory

This article explores the strengths and limitations of settler colonial theory (SCT) as a tool for non-Indigenous scholars seeking to disturb rather than re-enact colonial privilege. Based on an examination of recent Australian academic debates on settler colonialism and the Northern Territory intervention, we argue that SCT is useful in dehistoricizing colonialism, usually presented as an unfortunate but already transcended national past, and in revealing the intimate connections between settler emotions, knowledges, institutions and policies. Most importantly, it makes settler investments visible to settlers, in terms we understand and find hard to escape. However, as others have noted, SCT seems unable to transcend itself, in the sense that it posits a structural inevitability to the settler colonial relationship. We suggest that this structuralism can be mobilized by settler scholars in ways that delegitimize Indigenous resistance and reinforce violent colonial relationships. But while settlers come to stay and to erase Indigenous political existence, this does not mean that these intentions will be realized or must remain fixed. Non-Indigenous scholars should challenge the politically convenient conflation of settler desires and reality, and of the political present and the future. This article highlights these issues in order to begin to unlock the transformative potential of SCT, engaging settler scholars as political actors and arguing that this approach has the potential to facilitate conversations and alliances with Indigenous people. It is precisely by using the strengths of SCT that we can challenge its limitations; the theory itself places ethical demands on us as settlers, including the demand that we actively refuse its potential to re-empower our own academic voices and to marginalize Indigenous resistance.

Aboriginality and the Northern Territory intervention

Architects and supporters of the Northern Territory Emergency Response (the intervention) mobilised a range of ideas about Aboriginality to introduce and justify the policy program. These representations link Aboriginality to abuse of Aboriginal children, establishing a debate about the nature and future of Aboriginality in a context that limits the discursive authority of Aboriginal people. Aboriginality is represented as savage and in need of settler-imposed control, and also primitive and in need of development. These constructions understand Aboriginality temporally, situating it in the past but providing moral justification for coercing Indigenous people into the settler present. Aboriginality is also constructed spatially in this discourse, with prescribed communities framed as the location of both authentic Aboriginality and of threatening disorder. The intervention is framed as extending settler authority over this troubling terrain, containing and redeeming Aboriginality through inclusion in the settler nation’s moral order.

The vanishing endpoint of settler colonialism

In this paper, we interrogate the way that narratives about the unfolding of settler colonialism through time are encoded in recent Australian Indigenous policy frameworks. We argue that the postcolonial image of a single transformative moment of radical political break is embedded in Australian policy frameworks, but is deployed in ways that fuse this idea with the moment of colonial completion and in so doing assist the colonial project. By merging the moment of decolonisation and the moment of colonial completion, temporal narratives mobilise conservative and progressive settler voices towards colonial goals. We identify three recent policy approaches: reconciliation, neoliberal contractualism and intervention, and interrogate the narratives of the present and future that they reflect and deploy. We argue these unacknowledged stories of the colonial future must be contested, so that debates about how settler and Indigenous people might live together differently across time are not foreclosed.

Aboriginality and the Northern Territory intervention

This thesis examines the construction of Aboriginality in recent public policy reasoning through identifying representations deployed by architects and supporters of the Commonwealth’s 2007 Northern Territory Emergency Response (the intervention). Debate about the Northern Territory intervention was explicitly situated in relation to a range of ideas about appropriate Government policy towards Indigenous people, and particularly about the nature, role, status, value and future of Aboriginality and of Aboriginal people and Torres Strait Islanders. This project involves analysis of constructions of Aboriginality deployed in texts created and circulated to explain and justify the policy program. The aim of the project is to identify the ideas about Aboriginality deployed by the intervention’s architects and supporters, and to examine the effects and implications of these discourses for political relationships between Indigenous people and settlers in Australia. This thesis will argue that advocates of the Northern Territory intervention construct Aboriginality in a range of important ways that reassert and reinforce the legitimacy of the settler colonial order and the project of Australian nationhood, and operate to limit Aboriginal claims. Specifically, it is argued that in linking Aboriginality to the abuse of Aboriginal children, the intervention’s advocates and supporters establish a political debate about the nature and future of Aboriginality within a discursive terrain in which the authority and perspectives of Indigenous people are problematised. Aboriginality is constructed in this process as both temporally and spatially separated from settler society, and in need of coercive integration into mainstream economic and political arrangements. Aboriginality is depicted by settler advocates of intervention as an anachronism, with Aboriginal people and cultures understood as primitive and/or savage precursors to settlers who are represented as modern and civilised. As such, the communities seen as the authentic home or location of Aboriginality represent a threat to Aboriginal children as well as to settlers. These constructions function to obscure the violence of the settler order, provide justification or moral rehabilitation for the colonising project, and reassert the sovereignty of the settler state. The resolution offered by the intervention’s advocates is a performance or enactment of settler sovereignty, representing a claim over and through both the territory of Aboriginal people and the discursive terrain of nationhood.

Treaty talk : past, present and future -- [Edited version of the inaugural Ngunnawal Lecture at the University of Canberra]

WELL I HEARD it on the radio and I saw it on the television. John Howard said there would be no talk of a treaty between his government and Indigenous people. He is not the first government leader to hold such views. Let me consider some of the public and official conversations that the concept of a treaty has invoked and what they reveal about white sovereignty. My interest in such dialogues stems from the fact that the idea of a treaty between white Australia and Indigenous people is not new and in the year of the centenary of Federation the Australian nation is still having trouble discussing it. Australian culture is less white than it used to be, but Anglicised whiteness forms the centre where white men established and defend institutions encouraging a possessive investment in white sovereignty. My intention is to invoke critical thought about these conversations. White sovereignty is a subject that asserts its dominance on social, political...

The promise of justice reinvestment

Abstract: This article examines the notion and practice of Justice Reinvestment (‘JR’), an emerging approach addressing the high social and economic costs of soaring incarceration rates. JR invests in public safety by reallocating dollars from corrections budgets to finance education, housing, healthcare, and jobs in high-crime communities. Key distinguishing features of JR (including justice and asset mapping, budgetary devolution and localism, and the desirability of bipartisanship) are briefly outlined, followed by discussion of its recent emergence and application in the United States, and to a lesser extent in the United Kingdom. The prospects for the adoption of JR approaches in Australia are then considered, with particular reference to the high imprisonment rates of Indigenous people. If JR is to be promoted in the Australian context it is important that it be subject to critical scrutiny and therefore some of the key problems are briefly outlined, before a conclusion which emphasizes the potential benefits of JR.