Victorian Auditor-General's report 
10 October 2012 
Consumer participation in the Health System
Audit summary
Consumers should be meaningfully involved in decision-making about their health care and treatment, and broader health policy, planning and service delivery. There is growing recognition and evidence that consumer participation: 
·	positively influences an individual’s health outcomes if they are given quality information and are actively involved in decisions
·	improves quality and safety by helping to design services that meet consumer needs
·	provides feedback to drive service improvement
·	enhances accountability by openly and transparently reporting on performance to consumers.
The audit assessed the extent to which the Department of Health (the department) and public health services facilitate meaningful consumer participation, including whether consumers are:
·	supported to actively participate in their health care
·	actively involved at the health service level
·	actively involved at the departmental level.
Conclusions
There is genuine commitment and effort from the department and health services to facilitate meaningful consumer participation. The department has led the implementation of consumer participation through strong policy direction and setting clear expectations. This has translated into appropriate policies, systems and activities in the four audited health services. 
The department and health services acknowledge the benefits of consumer participation in areas such as quality, safety and patient experience. There is evidence that having consumers on committees and working groups, and the use of consumer feedback have improved health service delivery, for example, in hospital signage, food services, information materials and physical facilities. 
Implementing consumer participation in the health system is relatively recent and is a challenging process, and therefore, the achievements vary. The extent of consumer participation varies both between and within health services, as well as within the department. There are opportunities to enhance consumer participation at all levels, including by better supporting consumers to understand and engage with basic health service information, and better involving consumers in organisational strategic planning and evaluation. This will become increasingly important as new national accreditation standards are implemented from January 2013, with significantly higher expectations and evidence requirements for consumer participation.
The department and health services have a comprehensive range of policies and frameworks to support and encourage consumer participation. However, health services do not always provide sufficient staff training, resources or support for consumer participation to be successfully integrated into service delivery and improvement. 
The quality and availability of information within health services varies considerably, as does the effectiveness of communication between consumers and staff. Consequently, while many consumers are supported to make informed decisions and participate actively in their health care, others are left as passive recipients of health services that are decided by medical and nursing staff. Health services recognise that there are also additional challenges in meeting the needs of those from culturally diverse backgrounds or with special needs. 
The department’s leadership has firmly placed consumer participation on the agenda of Victoria’s public health services. However, to further improve, the department needs to address gaps in its own implementation of consumer participation, provide better oversight of health services’ consumer participation activities, and integrate consumer participation more broadly across the department. 
The department requires health services to report on a range of consumer participation activities. However, it provides minimal feedback to health services about their performance. The department’s existing health service performance framework should better integrate consumer participation reporting. The department also needs to monitor and evaluate departmental consumer participation activities, continue to provide regular staff training in consumer participation and showcase successes across program areas.   
Findings
Individuals’ participation in their health care
The department plays a major role in developing and disseminating consumer information, and assisting consumers to be actively involved in their health care. However, there is a gap in the availability of reliable, up-to-date information about common health issues in community languages. 
Health services produce and disseminate a wide range of consumer information through brochures, posters, websites, patient information guides and visual display boards that outline service and quality. However, the quality and availability of consumer information was poor in one of the audited health services. Essential information, including service guides, patient rights and responsibilities, how to access an interpreter and how to provide feedback were not prominently displayed or readily available to patients throughout the health service. 
Interviews with 52 patients across the four audited health services suggest that awareness and understanding of basic health service information is low. Health services need to increase efforts to disseminate critical information on rights, responsibilities and complaints processes through multiple and meaningful channels.
Each of the four audited health services had robust systems for collecting, reporting and addressing consumer feedback and complaints. This included: using a variety of formal and informal processes, capturing information on both compliments and complaints, seeking to resolve potential issues at the coalface, and reporting results at all levels of the organisation.
All four audited health services are making efforts to improve participation by diverse consumer groups. Examples include creating welcoming and culturally sensitive environments for members of the Aboriginal and Torres Strait Islander community, multi-faith facilities, and improved access for people with disabilities.
Health services report a range of challenges in implementing their interpreter policies. They report that funding for interpreter services has not kept pace with consumer needs, demand has increased and there is a shortage of interpreters in some languages. Health services in rural and regional areas face additional barriers, such as a smaller local pool of accredited interpreters and increased travel time and costs. This issue warrants departmental review given the legal and ethical imperative to provide interpreters. 
Consumer participation in health services
The audited health services have consumer participation frameworks in place, including documented policies and procedures and consumer representation on a range of committees and working groups. However, they are at varying stages of embedding consumer participation in organisational culture. 
The audited health services are aware of the need to train staff at all levels of the organisation in consumer participation. They report that a major cultural shift, particularly among frontline clinical staff, is required to put consumer participation at the forefront of health care. Despite this awareness, two of the audited health services had inconsistent, ad hoc approaches to developing, implementing, monitoring and reviewing staff training in consumer participation.
Three of the four audited health services are legislatively required to have a community advisory committee (CAC) in place. The other, a small rural health service, has also elected to have a consumer liaison group. 
The department’s CAC guidelines require CACs to develop a community participation plan (CPP) for approval by the board, and to monitor its implementation and effectiveness. 
All three of the audited health services required to have a CPP have a plan with objectives, actions and time frames aligned to their strategic plan. However, some of the plans did not address all of the basic expectations set out by the department, suggesting that CACs and boards need to review their plans against the guidelines.
Health services report challenges in recruiting and retaining committee members who reflect the diversity in the local community, and/or building the capacity of members to operate at a strategic level. Committees also vary in the level of support they receive from health service boards and executive staff, and resources and guidance provided to support and focus their activities. 
There is sound evidence of consumer input into health service decision-making at a program level at each of the four audited health services—for example, in improving individual clinical services. However, there is mixed success in involving consumers in strategic planning, staff training and health service performance monitoring, and little evidence of consumer participation in evaluation activities.
It will be challenging for many health services to meet the consumer participation requirements under the new National Safety and Quality Health Service Standards for health service accreditation. There is a significantly increased focus on consumer participation compared with previous requirements, as well as a more rigorous and robust assessment. Health services will need to address existing gaps in consumer participation activities to allow them to demonstrate compliance.
Consumer participation in the Department of Health
The department has provided strong policy direction for consumer participation through the 2006 Doing it with us not for us policy. This policy has a robust evidence base and was developed in consultation with consumers. However, the department has not fully evaluated its impact, nor planned to do so for the current version which expires in 2013. The department should review the status and usefulness of its policy within the context of the new national accreditation standards and the overarching Victorian Health Priorities Framework. 
The department funds the Health Issues Centre and the Centre for Health Communication and Participation to progress research, health professional education, evaluation, and training in consumer participation. There is an opportunity for the department to address a current evidence gap by supporting research into the economic and health outcome benefits of consumer participation.
Departmental monitoring of health services’ compliance with consumer participation policy and reporting requirements is minimal. While the department acknowledges whether health services submit required tasks, its staff do not provide specific feedback to health services on the quality or appropriateness of their activities. There are also inadequate links between the assessment of consumer participation and the broader performance monitoring framework used to assess health services’ performance. Greater inclusion of consumer participation achievements in overall assessment would act as an important driver for improvement. 
Recommendations
Number	Recommendation	Page	
	That health services:		
1.	involve consumers in the design and review of consumer information	17	
2.	make sure consumers receive and understand basic health service information	17	
3.	review and improve service delivery for culturally and linguistically diverse consumers, including the provision of interpreters.	17	
4.	That the Department of Health review interpreter services in the Victorian health system.	17	
	That health services:		
5.	provide consumer participation training and development for clinical, middle management and executive level staff	32	
6.	increase and diversify consumer participation in strategic planning, staff training, and evaluation activities.	32	
	That the Department of Health:		
7.	integrate consumer participation across the department 	44	
8.	provide meaningful feedback to health services on reported consumer participation activities linked to their overall performance assessment	44	
9.	evaluate the impact of Doing it with us not for us: Strategic direction 2010–13	44	
10.	update its consumer participation policy and guidelines in the context of new national accreditation standards and the Victorian Health Priorities Framework.	44	

Submissions and comments received
In addition to progressive engagement during the course of the audit, in accordance with section 16(3) of the Audit Act 1994 a copy of this report was provided to the Department of Health and four audited health services with a request for submissions or comments.
Agency views have been considered in reaching our audit conclusions and are represented to the extent relevant and warranted in preparing this report. Their full section 16(3) submissions and comments are included in Appendix A.