International Comparison
Very little information has been available about any similar guidelines in use in other countries. In Australia, the model is being used in states other than New South Wales for both long-term planning and inter-regional comparisons, but has apparently not been formally adopted outside NSW. Even those involved closely in use and development of the role delineation model were not aware of similar models elsewhere, although the principles involved would be similar to the standards of the Medical Colleges.
It is worth noting that Medical Colleges here and overseas are increasingly moving to restrict the scope of practice for their members to areas of proven competence as the trend to specialisation in medicine continues. In future they may also specify which procedures may be carried out at which hospitals, based on the level of facilities and support services available (CHEEU, 1993b: Annex 7, p 3). Internationally and nationally, there is an increasing focus on the use of Best Practice Guidelines to determine effective, appropriate health and disability service delivery.
In the USA, the California Alternative Rural Hospital Model provides some similarities (Agency for Health Care Policy and Research, 1991:5). It takes a "building block" approach, with a set of basic and support services defining the core, with additional modules possible if the support services are expanded to match.
Use of the Role Delineation Model in New Zealand
The NSW model was first used in New Zealand in September 1991 to assess services at Whakatane hospital. This was part of a larger exercise identifying gaps and core services in the Bay of Plenty. The other two hospitals in the area have since also been evaluated using the model. From the results, the BOP CHE have defined a core of services to be offered by all three hospitals, and plan to rationalise other services between the three. (Dutton, pers.comm.)
In July 1992, CHE Advisory Committees (CHEACs) were established and given the task determining the "shape" of CHEs evolving from the AHB configuration. This involved assessing which hospitals were clinically and economically viable on their own. The NIPB recommended use of the NSW model in this process, and it was subsequently used in 10 of the 14 Health Board areas. It was found that the model worked well for this purpose.
One of the results of the CHEAC process was the identification of four hospitals in which the levels of clinical services provided were not matched by the level of support services available. This finding of "unsafe" hospitals generated considerable media attention at the time. In all cases the AHBs involved took steps to address the problems brought to light by the use of the model. (CHEEU, 1993a)
The model was also used in October 1992 at Wairoa and Waipukarau hospitals to evaluate their potential as community trusts.
Midland RHA used the guidelines last year to examine the surgical, medical, obstetrics and gynaecological services provided by the CHEs in their region. The purpose was generally to take an inventory to assist with future planning and to identify any gaps in service. They may use the levels defined in the guidelines to define the levels of services to be purchased from CHEs in future years. In fact, it was suggested that funding would be restricted to the agreed level, in other words, if a CHE was funded to provide surgery at level 4, it would only be paid to do surgery at this level, even if it performed some at level 5.
A number of private hospitals have also made use of the guidelines to assess the services they offer. In many cases these hospitals do not have on-site support services, but are able to claim use of support services offered by public services to which they have access (Dutton, pers.comm.).
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Rural Affairs Coordinator
Sector Performance Policy
MAF Policy
Ministry of Agriculture and Forestry
PO Box 2526
Wellington
NEW ZEALAND
Phone: +64 4 894 0675
Fax: +64 4 4 894 0745
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