Health services

Objectives To identify drivers of routine vaccination for Aboriginal and Torres Strait Islander children, from a health service provider perspective, to increase and maintain uptake.DesignThis qualitative study was designed, analysed and guided by Indigenous data sovereignty and governance principles. Data were analysed using inductive content analysis. Subcategories were refined using Miro (Miro Inc), an online collaboration platform. Aboriginal and Torres Strait Islander worldviews were privileged, with Aboriginal researchers leading data analysis in New South Wales (NSW) and contributing to analysis in the Northern Territory (NT).SettingThe study was conducted in NSW and the NT, Australia, with health service providers from urban, rural and remote settings.ParticipantsIndividual and group interviews were undertaken in person or online between 2 May and 28 August 2024, with 18 health service provider participants in the Hunter New England Local Health District in NSW and 17 health service provider participants in the NT.ResultsWe identified six key themes addressing drivers of vaccination for Aboriginal and Torres Strait Islander children for families (knowledge, attitudes and information sources; decision-making), health staff (workforce roles, responsibilities and relationships) and health services (improving access; health service operations; data for decision-making). Providers recommended strategies to improve uptake.ConclusionsHealth service providers in urban, rural and remote locations in Australia can provide valuable insights to inform tailored strategies to improve declining vaccine coverage for Aboriginal and Torres Strait Islander children, aligned with the priorities of the National Immunisation Strategy 2025–2030.

Bianca F. Middleton, Kristy Crooks, Kylie Taylor, Elizabeth Harwood, Katrina K. Clark, Caitlin Kent, Kelly McCrory, Marita Hefler, Jessica Kaufman, David N. Durrheim, Margie H. Danchin

This editorial highlights three studies that collectively offer a roadmap towards system-level improvement in access, flow and quality of care. These studies used linked data from several Queensland hospitals and explored emergency department (ED)–hospital capacity associations with ambulance, ED and hospital dysfunction. One study found ED occupancy was strongly associated with ambulance dysfunction (ramping, response times). The second study associated hospital occupancy with ED dysfunction. Larger hospitals with occupancies above 85%–90% became dysregulated with rapid overcrowding. The modelling study in three tertiary hospitals reported that reduced admissions (ED or elective procedures), improved discharges (earlier, quicker community discharge, home care) and flexible bed use (any ward, over-census) improved flow. Diverting general practice–type attendances and weekend surgery seemed ineffective. Rapid, adequate flexible admitting capacity seems important for safe, efficient hospital–ED care and ambulance function.

David Mountain

Objective To assess the impact of strategies to improve public hospital emergency access using a detailed ward-level simulation modelling approach. Design and Setting Discrete event simulation was used to simulate patient flow at three principal referral Australian hospitals from 1 September 2021 to 31 August 2022. Models were developed and validated using every emergency department (ED) presentation, inpatient episode of care and patient ward movement at the study hospitals. Main Outcome Measures Mean and total ED length of stay, mean waiting time, access block rate, 4-h rule compliance and bed utilisation for patients admitted from the ED. Results Reducing ED demand via arrangements that accommodate the same proportion and types of admissions from the ED as the existing ED presenting population reduces access block, with larger impacts in winter than in summer. However, reducing ‘general practitioner-type patients’ in EDs has negligible impact on access block. Tangible impacts on improving patient flow can be achieved by removing maintenance care patients from hospitals (reducing the percentage of access block by up to a third) and reducing elective admissions. Strategies that emphasised morning, midday and early afternoon discharges led to large flow improvements. The strategy already practised by most hospitals of sharing patients among wards greatly improves emergency access, and gains are the same order of magnitude as reducing overall ED demand. Conclusions The study provides support to policymakers looking for evidence regarding strategies to improve emergency access to public hospital care.

Hamed Hassanzadeh, Justin Boyle, Vahid Riahi, Hwan-Jin Yoon, Ibrahima Diouf, Sankalp Khanna, Clair Sullivan, Andrew Staib, Emma Bosley, Mahnaz Samadbeik, James F. Lind

Over recent decades, the medical profession has undergone significant changes due to the influence of managerialism, which is characterised by standardisation, efficiency and cost control. Although these principles aim to improve sustainability and transparency within healthcare systems, they often conflict with fundamental aspects of medical professionalism and patient-centred care. This perspective explores how managerialism may negatively affect the medical profession, focussing on its impact on clinician autonomy, the changing nature of medical work, professional identity and collegial relationships within hospital settings. Key challenges faced by doctors include diminishing control over patient care, growing administrative burden, increasing burn-out, erosion of professional values and identity, and fragmentation of collegiality. To address these issues, this perspective advocates for institutional change such as hybrid governance models that integrate professional and managerial expertise to ensure managerial goals remain aligned with clinical realities. Professional bodies and institutions should empower doctors with managerial and leadership competencies to influence organisational change, reconcile clinical and managerial priorities, and uphold professional values and quality patient care within the evolving healthcare landscape. Effective reform requires the considerate integration of managerial systems into healthcare to strengthen, rather than undermine, the professional foundations and ethical values that give medicine its integrity and meaning.

Evelyn He, Behnam Shaygi, Anousha Yazdabadi, Christen D. Barras, Paul M. Parizel, Hamed Asadi