Timelines and descriptions

No performance indicator has meaning without context. For it to be meaningful it needs comparators and an understanding of the environment in which it is used. This means that to understand the use of elective surgery waiting times as performance indicators for the Australian public hospital system, they must be put into the context of both the hospital system and the wider political and funding context for the

Australian public health system. The context is complicated by responsibility for public health belonging primarily to Australian States and Territories but with much of the funding coming from the Commonwealth level of Government. Details of the

relationship between the different levels of government in Australia and the detailed effect of this on the public hospital system are given in Chapter 3.2.1 starting on page 61.

Information describing the public health system and its governance is available from a range of public documents including:

• Formal agreements between the Commonwealth government and the

State/Territory Governments

• Legislation, both State/Territory and Federal • Policy documents

• Formal Reports

• National and international standards

Many of these documents contain a short summary of the recent history of the Australian public health system as well as details relating to the specific purpose of the document.

The inter-governmental agreements and legislation are the most formal

documentation of how accountability and performance measure are used within the public health system but they are by no means the only sources of information. The agreements take many months to negotiate and so are slow to react to changing circumstances. Legislation is similarly slow to change, given the need for formal drafting and multiple parliamentary votes. Neither type of document typically includes operational or purely administrative information. This more detailed information is contained in a range of supporting agreements and administrative orders. The next level of documentation is local policy and implementation

documentation which further refines the higher-level guidelines in accordance with state/territory needs.

Table 3-1: Documentation relating to the different levels of governance in the

public hospital system

Level of governance Type of documentation

World Health Organisation Internationally agreed classification of health interventions

International Standards

Organisation Internationally agreed standards for data collection and management. Australian institute of Health

Level of governance Type of documentation Australian Commonwealth

Government Commonwealth legislation _{• Taxation, including Medicare levy and Goods} and Services Tax (GST)

• National health policy, mainly relating to primary care

Council of Australian

Governments Agreements between the Commonwealth government and State/Territory governments • National Health Reform Agenda

• GST distribution

Performance reporting of achievement against goals in reform agenda documents

State/Territory governments State/territory legislation State/territory health policy

Consolidated data from hospitals within the State/Territory

Individual Public Hospitals Day-to-day management, policy and procedural documentation

Initial data gathering

When it comes to data definitions and reporting, the highest level specifications are the international standards relating to the collection and reporting of health-related data produced by the World Health Organisation (WHO). These standards underlie the Australian standards and specifications managed by the Australian Institute of Health and Welfare (AIHW). These are described in more detail in Chapter 3.3.4 Data Collection on page 91.

My initial source of documents was the Council of Australian Governments (COAG) Reform Council website (www.coagreformcouncil.gov.au/) and this remained one of my principal sources. The COAG Reform Council is a part of the arrangements for financial relations between the Commonwealth government and the

States/Territories. The time of this research coincided with the National Health Reform Agenda, a process managed by COAG to improve the entire Australian public health system and reallocate funding responsibilities between the

Commonwealth and State/Territory Governments. The formal reports and submissions relating to the reform agenda contained references leading back to the underpinning legislation, data definitions and high-level policy documents relating to the public hospital system in Australia. From these I was able to identify those that dealt specifically with elective surgery waiting times.

As well as this top-down approach starting at the Commonwealth level, I also started at the local level, searching the ACT Health Directorate website for policy and procedures relating to elective surgery in public hospitals. Links at this level led both up to the wider Commonwealth/State level as well as down to detailed local

procedures and implementation guidelines.

From the information in the source material I synthesised two accounts relating to the background and context in which elective surgery waiting times are used as performance indicators for the public hospital system:

• The Australian public hospital system

This describes how the Australian public hospital system is managed and funded within the context of Commonwealth/State relations and the effects of the National Health Reform Agenda. It describes how and when elective surgery waiting times are used as performance indicators in this context.

• Elective Surgery Waiting List data

This describes the lifecycle of the waiting list data from formal data

definitions, through the overall administrative processes for elective surgery in the ACT public hospital system, to the first official public reporting of the indicators.

During 2010-2011, the time period covered by this research, the political and

funding environment for the Australian public hospital system was in a constant state of flux. There was major reform of how funding and accountability were allocated between the States/Territories and the Commonwealth and instability in the Commonwealth government which eventually lead to a change in that level of government in 2013. The two possible approaches for this part of my research project were to:

• choose a point in time and provide an accurate, detailed description of the system as it was then; or

• document the evolving nature of the overall environment during the research period.

I chose the latter, primarily because the publication of elective surgery waiting time data was one of the key indicators used to drive and monitor the reform agenda. The

period covered is the same as that covered by the articles in The Canberra Times, January 2010 to December 2011.

Creating an account of historical events from the documentary record was not straightforward. The process ended up as a feedback loop from discovering information, fitting it into the narrative, finding gaps or contradictions in the

narrative and searching for further information. This process is admirably described by Ludmilla Jordanova in her book History in Practice:

It is unhelpful to think about historical research as a simple sequence of tasks that should be performed in a given order. In fact, historians constantly move between the main types of activity they perform, namely, engaging with sources, delineating a problem, setting it in broad contexts, developing a framework and constructing arguments in written form.

(p159, Jordanova 2006)

Although all the source documents contributing to the narrative were in some sense “official” each had been created by a specific entity for a specific purpose. This meant that each had its own particular perspective on elective surgery waiting times, public hospitals, the wider public health system, and the overall Australian political system. The emphasis of the documents could range from a focus on financial matters, to specifications of reporting requirements to details of how the waiting lists themselves were to be managed. Some documents, such as official performance reports, were primarily descriptive; others such as policy proposals produced early in the reform process were primarily persuasive.

Constructing a coherent overview from these disparate sources meant that I had to reconcile a range of subtly different ways of looking at the issues involved. This process is covered at length by Jordanova in Chapter 7: Historians’ Skills of History in Practice (Jordanova 2006). As she observes, “…in reality the important skills lie in tracking down information and knowing how to deploy it thoughtfully rather than in remembering it.” (p151, Jordanova 2006). This quote emphasises the importance of the link between straight content and the interpretation of that content within a particular context.

Where possible I used information that I could find in two or more sources. When I had to make a decision about how to represent something that was shown differently

in different sources I chose the description that fitted best with the material around it. I kept firmly in mind that I was researching this from a communication perspective, so I also gave priority to any source material that shed light on how the performance indicators were to be communicated and interpreted. As an example, when covering the establishment of the National Health Performance Authority, I focussed on its reporting role and the State/Territory negotiations about how data was to be presented and compared, rather than the details of the debate about how the authority was to be funded. This business of selecting sources based on context is outlined in Anthony Seldon’s Preface to Contemporary History:

Above all the contemporary historian must beware the seductive temptation of regarding any data as objective and final: there are always vital contextual questions to be asked. (p2, Seldon 1988)

Inevitably I dealt with both primary and secondary sources. As mentioned above, many of the later reports and supporting documentation gave short summaries of one aspect or another of the background and history of the elective surgery waiting list data. The common points of these summaries formed the basis of my timelines. Cross-checking these secondary accounts against the available primary documents gave me a way of validating some details.

As well as the formal documentary record there is also an unwritten history stored in the memories of the people involved at all levels in the provision of elective surgery in the Australian public hospital system. As Nicholas Cox points out, “We can only find on file what was put there at the time” (p82, Cox 1988). There will always be details of processes and decisions that are not captured in either the confidential or the public record because they arose from informal discussions and exchanges. What ever is written later about the basis of these decisions will always be a selection and interpretation of what happened. Since my focus is on the public aspect of

communication about elective surgery waiting lists, not the communication between informed individuals within the system, I deliberately used only sources available to a determined member of the public. As I became more informed I discovered more sources but still kept to those on the public record.

The most common medium for these public documents was official and semi-official internet sites. The rise of the internet as a means of making information available to the public has greatly changed the nature of research into contemporary history.

While searching government websites might be quicker than searching hard-copy archives, sending off for printed reports and submitting Freedom of Information requests it comes with its own set of limitations. As Brian Head points out in The Public Service and government communication: Pressures and dilemmas (Head 2007) it is all too easy for information provision to become entangled with government marketing. This makes it all the more important to look for information from non-government sources and independent statutory bodies as well as that provided directly by government departments.

Using only public sources meant that I dealt with the same information as that presented to the public and could focus on analysing it and its communication consequences. Collecting the oral history associated with the background to the use of elective surgery waiting times as performance indicators would be a major piece of research in its own right and is beyond the scope of this research project.