Public health approaches to palliative care in Australia

1
Public health approaches to palliative care in
Australia

• Bruce Rumbold, Palliative Care Unit, La Trobe
  University, Victoria, Australia

2
Palliative Care in Australia

• UK hospice influence
• Local community programs
• Survival engaging the health system
• Mainstreaming (accessing government funding
• Public health approaches
• Needs-based service provision

3
The Australian health care system

• Universal insurance
• Private insurance increases choice and
  fast-tracks elective procedures
• Federal and state health care systems
• Division of funding responsibilities mediated by
  Australian Health Care Agreements

4
HOSPICE

• Hospice has therefore adopted these principles -
  openness, mind together with heart, and a deep
  concern for the freedom of each individual to
  make his or her own journey towards their
  ultimate goals.
• Saunders, C. (1996) HospiceMortality 1
  (3),317-322, p. 319

5
Hospice programs in Australia

• Stand-alone facilities
• In-patient units in hospitals or nursing homes
• Community care programs

6
Mainstreaming hospice becomes palliative care

• Gains
• recurrent health care funding
• improved access to palliative care
• career pathways for practitioners
• secularisation

7
Mainstreaming hospice becomes palliative care

• Risks arising from
• Medical dominance of philosophy of care
• Professionalisation
• Secularisation
• Loss of links with local community
• Competitive tendering disrupting information
  sharing, standards and accountability

8
Key requirements of mainstreaming

• Medical practitioner support and involvement
• Political/bureacratic support
• Continuing community acceptance of medical
  management of dying

9
Under-developed areas of palliative care

• Social science and public health perspectives
• Social and spiritual aspects of care
• Early stage care
• Active treatment of disease
• Care for those with life-threatening (not just
  terminal) illness

10
Promoting health?OTTAWA CHARTER

• Enable, mediate, advocate
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Reorient health services

11
Health Promoting Palliative Care

• Provide education and information for health,
  death and dying
• Provide social supports, both personal and
  communal
• Encourage interpersonal reorientation
• Encourage reorientation of palliative care
  services
• Combat death-denying health policies and
  attitudes
• Kellehear, A. (1999) Health Promoting Palliative
  Care, Melbourne, Oxford University Press

12
Health Promoting approaches

• Complement clinical approaches
• Encourage community alliances
• Challenge current health policy
• Restore social and pastoral interventions
• Allow for diversity amongst clients
• Expand understandings of health
• Reclaim an holistic perspective

13
Reception and Implementation

• Reception a spectrum of response
• Implementation
• Life Support Program
• Incorporation in Palliative Care Australia policy
• Schools-based death education program
• Building rural community capacity through
  volunteering
• Integrating HPPC in a palliative care service
• Workplace support
• Strengthening palliative care in Victoria through
  health promotion

14
The Big Seven

• PREVENTING social difficulties around death,
  dying, loss
• HARM-MINIMISING difficulties
• INTERVENING EARLY to address difficulties
• Changing SETTING or ENVIRONMENT
• PARTICIPATORY
• SUSTAINABLE
• EVALUATED
• At least one of 1-3, and all of 4-7, should be
  demonstrated

15
Public health initiatives in palliative care

• Community development
• Community education
• Prevention strategies aimed at reducing social
  morbidity
• Social policy, practices advice
• Palliative Care Australia (2003) Palliative Care
  - service provision in Australia a planning
  guide (second edition), Canberra, Palliative Care
  Australia, p. 13

16
Goals of population based planning

• All dying people are able to access timely, high
  quality care appropriate to their needs
• All dying people receive care consistent with
  their level of need
• Resources are appropriately distributed across
  the health care system and utilised based on
  level of need
• All health professionals have an understanding of
  the public health, primary and specialist domains
  of palliative care and how they interact with
  each other

17
Assumptions made in population health model

• The greater proportion of the needs of dying
  people can be appropriately met by primary
  palliative care providers or services
• A proportion of these dying people may require
  consultation with a specialist palliative care
  service for the assessment and/or management of
  symptoms/conditions that exceed the capacity of
  the primary palliative care providers
• A smaller number of these dying people will
  require ongoing direct involvement from a
  specialist palliative care service

18
Some implications

• Responsibility for care of dying people and
  families disseminated through the health system
  and the community in general
• Increased responsibility for informal care-givers
• Ongoing consideration of other forms of a good
  death
• Shift from palliative care provision to a
  palliative care approach
• Specialist services increase consultation,
  (possibly) reduce direct service

19
Public Health Palliative care requires

• A policy framework that recognises and
  legitimates community-based initiatives
• Partnerships amongst healthcare providers and
  community organisations to extend and enhance
  palliative care practice
• Local community action to raise awareness and
  develop community capacity in end-of-life care

20
What we have going for us

• Tradition of community activism and voluntarism
• Social marketing raising awareness of palliative
  care
• National training programs
• Awareness of, and interest in, community
  development approaches within many palliative
  care services

21
Partnerships levels of engagement

• Strengthening a communitys capacity to care for
  members currently encountering death and loss
• Building resilience to deal constructively with
  limitations and change
• Develop social capital, the foundation of
  resilience and capacity to care

22
Hurdles to negotiate

• Health services or public health approaches?
• Palliative care, or end of life?
• Integration or absorption of palliative care?
• Working the boundaries
• Opportunity or risk health services or community
  control
• Evidence based policy
• Genuine choice right options for the right
  people preserve social identity and contribution

23
Public health research and policy

• Interventions identify issues of theoretical
  significance for example
• Fine structure of professionalism embedded
  epistemologies
• Negotiating clinic-community boundaries the
  contribution of volunteers
• Managing dying choice and control

24
HPPC Programs

• Strengthening Palliative Care Through Health
  Promotion
• Funded by DHS Victoria
• Health Promotion Workers appointed, funded,
  trained and supervised to work with regional
  palliative care consortia