23 results for Ashton, Toni

  • The organization and financing of dialysis and kidney transplantation services in New Zealand

    Ashton, Toni; Marshall, MR (2007)

    Journal article
    The University of Auckland Library

    In New Zealand, patients receive treatment for end-stage renal disease (ESRD) within the tax-funded health system. All hospital and specialist outpatient services are free, while general practitioner consultations and pharmaceuticals prescribed outside of hospitals incur copayments. Total ESRD prevalence is 0.07%, half the U.S. rate, and the prevalence of home-based and self-care dialysis is the highest in the world. Medical staff are not subject to direct financial incentives that could affect treatment choice. Estimated total expenditure per ESRD patient is relatively low. Funding constraints encourage physicians and patients to consider the probable benefit of dialysis for a patient before treatment is prescribed.

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  • New Zealand

    Ashton, Toni (2009)

    Book item
    The University of Auckland Library

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  • Superannuation in New Zealand: Averting the Crisis

    Ashton, Toni; St John, S (1988)

    Book
    The University of Auckland Library

    To date New Zealand has suffered a number of piecemeal changes to public superannuation schemes, and this book argues for a complete overhaul of the system in the light of the economic environment and the concerns for all people to enjoy a reasonable standard of living. Toni Ashton and Susan St John argue that such a complete overhaul is necessary because of the implications for the whole society of any alterations to retirement incomes. Already there has been a lot of publicity about the tax burden on the younger working population if the stsus quo is maintained, and the issues of economic growth and social equity are paramount. It is hard to escape the conclusion that the issues are not simply how best to provide an integrated policy package for retirement incomes, or whether schemes are funded of unfunded, but how to ensure an adequate redistribution from wealthier New Zealanders to poorer New Zealanders in general, and how to secure adequate growth of output to improve the base for such redistribution in the context of a growing retired population.

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  • Quasi-Markets and Contracting for Health Services

    Ashton, Toni (1999)

    Doctoral thesis
    The University of Auckland Library

    ln 1993, the New Zealand health system was radically restructured. Area health boards, which were responsible for both purchasing and providing health services, were replaced by a quasi-market system in which public and private providers compete for public funds via contracts with purchasers. This thesis employs transaction cost economics (TCE) to examine the theory, the policy and the practice of the emerging quasi-market for health services in New Zealand. The main hypothesis which emerges from TCE is that contractual arrangements, which differ in their costs, will be aligned with transactions, which differ in their attributes, in a way which minimizes the sum of production and transaction costs. If services involve specific assets, or are difficult to measure and monitor, the transaction costs of contracting are likely to be high. The structure of the New Zealand health system prior to and after 1993 are described and analysed. Features of the emerging quasi-market include monopsonistic regional purchasers, a highly concentrated market for hospital services, weak budget constraints for CHEs, and a lack of competitive or political neutrality. All of these factors tend to dilute any incentives for efficiency. The TCE framework is used to examine the early contracting experiences and contractual relationships for four different health services: rest homes, primary health clinics, surgical services and mental health services. The selection of these four services was based upon a profiling of the characteristics which, according to TCE, are likely to influence the cost of transactions. The results support the central argument of the thesis. That is, that the costs of contracting are higher for some services than for others because of inherent differences in the attributes of different health services. A blunt policy instrument which forces a split between the roles of purchaser and provider for all health services fails to recognise these differences and may prohibit the development of organizational structures which might otherwise be selected as means of economizing on the transaction costs. Efforts must now be made to encourage a more discriminating approach to contracting in which a classical or neo-classical style of contracting is retained for those services where potential efficiency gains are high and the transaction costs of contracting are relatively low while longer-term relational contracts are developed for services where transaction costs are high.

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  • Reform and Re-reform of the New Zealand system

    Ashton, Toni; Tenbensel, Timothy (2010)

    Book item
    The University of Auckland Library

    This book presents the healthcare reform experiences of six small- to mid-sized, but dynamic, economies spanning the Asia-Pacific, the Middle East and Europe. Usually not given serious consideration in major international comparisons because of their small size, each in fact provides a fascinating case study that illuminates the understanding of the dynamics of healthcare reform. Although dissimilar in historical and cultural backgrounds, they share some important features : all faced very similar pressures for change in the 1970s and 1980s; all considered a very similar range of policy options; and all did not only discuss but actually implemented fundamental changes in their healthcare funding, organization, contracting and governance structures with strikingly different outcomes. All of the authors have lived and worked in one or more of the countries studied in this volume. The analytic frameworks they use reflect their broad range of professional and disciplinary backgrounds in health economics and political science. Beyond mere descriptions of reform processes and superficial analyses based on aggregate data from the usual OECD or WHO sources, they seek to understand - and explain - the variations in country experiences by examining the politico-socio-economic factors driving health reform as seen through the respective country lenses. In coming together in this unique international collaboration, they make an important contribution to the growing field of international comparative health policy studies.

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  • The silver tide: Late life care in ageing populations

    Broad, Joanna; Connolly, Martin; Kim, M; Ok, B; Ashton, Toni; Davis, PB (2015-09-29)

    Conference item
    The University of Auckland Library

    Decisions are increasingly needed to inform service provision for late-life care of older people. In New Zealand, residential aged care (RAC, equivalent to nursing homes elsewhere) is part of that service, but its use has not been well described. For example, in recent decades, reports of the percentage of those aged 65 years and over living in RAC has varied markedly. Since 2008 reports are more consistent, stabilising between 4%-6%. However, when place of death is analysed, a very different picture emerges – in New Zealand, of people who die aged over 65 years, 38% do so in a RAC facility. This is higher than any other country known, yet even so it does not include an unknown number who die in acute care having come from RAC.

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  • Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol.

    Jones, P; Chalmers, L; Wells, Linda; Ameratunga, Shanthi; Carswell, P; Ashton, Toni; Curtis, Elana; Reid, Mary-Jane; Stewart, Joanna; Harper, A; Tenbensel, Timothy (2012)

    Journal article
    The University of Auckland Library

    In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?

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  • Private Pensions in New Zealand: Can they Avert the 'Crisis'?

    St John, S; Ashton, Toni (1993)

    Book
    The University of Auckland Library

    The past five years have been a turbulent time for superannuation policy in New Zealand. This is nothing new. In the post-war period, there have been a number of dramatic changes as outlined in the earlier book by the authors, Superannuation in New Zealand, Averting the Crisis. What seems to be different in the early nineties is a sense of urgency, a need to end the policy instability and create certainty in the face of the impending demographic pressures. In many ways, New Zealand is very unusual with a tax neutral savings regime for private pensions and a non-contributory flat-rate state pension. As in other countries, there has been a strong move to encourage a shift away from state provision to take the 'burden' off workers of the future. The economic thinking behind this suggestion needs careful review. rather than assuming a shift will solve the problem, this book sets out a broader context in which all forms of public and private mixes can be evaluated against society's chosen income distribution objectives. This book was written during the period in which the government- appointed Task Force on Private Provision for Retirement was deliberating on how best to encourage greater self-reliance of retired people. The aim of this book is to contribute to the debate on the recommendations of the Task Force and to provide an historical and international context for that debate.

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  • Use of temporary nurse mechansisms by New Zealand's District Health Boards

    North, Nicola; Rasmussen, E; Hughes, F; Finlayson, Mary; Ashton, Toni; Campbell, T; Tomkins, S (2006)

    Journal article
    The University of Auckland Library

    Nursing shortages is a concern globally, and in this context has emerged a research focus on reasons and costs of turnover and retention. A national study on the costs of nursing turnover in New Zealand public hospitals was conducted between 2004-2006, with12 month’s data collected per randomly selected unit. Annual turnover rates were found to be high at average 39.16%, with a range of between 13.83% and 73.17%. Budgeted nurse staffing per unit in is expected to be sufficient to deliver nursing work for the patient population (occupancy, acuity and complexity) and provide for leave (annual, sick, study, family, bereavement etc). In the context of the study, it was assumed that temporary cover mechanisms were mainly to cover vacancies and occasional unplanned contingencies such as influenza affecting staff, and higher than normal demands for nursing work. The cost of temporary cover would therefore be a cost of turnover. An unexpected finding of the study was that temporary cover mechanisms were widely used, including when actual staff numbers were equal to or exceeded budget, and no consistent relationship with vacancies was evident. It was concluded that management of the nursing resource was driven by cost, not strategic, considerations. Published research on use of temporary cover and the effect of such practices on turnover of nurses provided a perspective to critique the finding.

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  • Where there's a will, is there a way? Is New Zealand's publicly funded health sector able to steer towards population health?

    Tenbensel, Timothy; Cumming, J; Ashton, Toni; Barnett, P (2008)

    Journal article
    The University of Auckland Library

    Since 2000, the substantive focus of health policy in New Zealand has been closely aligned to the agendas of improving population health and reducing health inequalities. Health system restructuring, through the introduction of locally based and partially elected District Health Boards (DHBs), was the structural mechanism chosen for reorienting the health sector towards population health. Strategic planning at the DHB level was the key mechanism by which central government population health objectives would be translated into local action. This analysis of the early years of elected DHBs (2001–2005) sets out to answer the following broad questions: (i) did strategic planning by District Health Boards reflect an orientation to population health?; (ii) to what extent was strategic planning towards population health shaped by community participation and input?; (iii) to what extent did strategic planning lead to a re-prioritisation of resources? These questions were explored as part of a larger research project investigating the introduction and implementation of the DHB system. Data were collected from over 350 interviews of local and national stakeholders, and two surveys of DHB Members between 2002 and 2004–2005. Overall, DHBs demonstrated the ‘will’ to engage in strategic decision-making processes to enhance population health but have difficulty in finding the ‘way’. The priorities and requirements of central government and the weight of institutional history were found to be the most influential factors on DHB decision-making and practice, with flexibility and innovation only exercised at the margins. This raises the key question of whether there is the governmental capacity at the local level to adequately address nationally determined population health policy priorities.

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  • Implementing new modes of governance in the New Zealand health system: an empirical study

    Barnett, P; Tenbensel, Timothy; Cumming, J; Clayden, C; Ashton, Toni; Pledger, M; Burnette, M (2009)

    Journal article
    The University of Auckland Library

    Health governance internationally has become more complex, with both hierarchical and network modes of governance explicitly represented within single public systems. Objective: To understand the implementation of new modes and mechanisms of governance under New Zealand health reforms and to assess these in the context of international trends. Research methods sought data from key groups participating in governance policy and implementation. Methods included surveys of board members (N = 144, 66% response rate), interviews with chairs (N = 14) and chief executives (N = 20), and interviews with national policy makers/officials (N = 19) and non-government providers and local stakeholders (N = 10). Data were collected over two time periods (2001/2002; 2003/2004). Analysis integrated the findings of both qualitative and quantitative methods under themes related to modes and mechanisms of governance. Results indicate that a hierarchical mode of governance was implemented quickly, with mechanisms to ensure political accountability to the government. Over the implementation period the scope of decision-making at different levels required clarification and mechanisms for accountability required adjustment. Non-government provider networks emerged only slowly whereas a network of statutory health organisations established itself quickly. Conclusion: The successful implementation of a mix of governance modes in New Zealand 2001-2004 was characterised by clear government policy, flexibility of approach and the appearance of an unintended network. In New Zealand there is less tendency than in some other some other small countries/jurisdictions towards centralisation, with local elections and community engagement policies providing an element of local participation, and accountability to the centre enhanced through political rather than bureaucratic mechanisms.

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  • Factors affecting delays in first trimester pregnancy termination services in New Zealand

    Silva, M; McNeill, Robert; Ashton, Toni (2011)

    Journal article
    The University of Auckland Library

    Objective: To identify the factors affecting the timeliness of services in first trimester abortion service in New Zealand. Method: Primary data were collected from all patients attending nine abortion clinics between February and May 2009. The outcome measured was delay between the first visit with a referring doctor and the date of the abortion procedure. Patient records (n=2,950) were audited to determine the timeline between the first point of entry to the health system and the date of abortion. Women were also invited to fill out a questionnaire identifying personal factors affecting access to services (n=1,086, response rate = 36.8%). Results: Women who went to private clinic had a significantly shorter delay compared to public clinics. Controlling for clinic type, women who went to clinics that offered medical abortions or clinics that offered single day services experienced less delay. Also, women who had more than one visit with their referring doctor experienced a greater delay than those who had a single visit. The earlier in pregnancy women sought services the longer the delay. Women's decision-making did not have a significant effect on delay. Conclusions: Several clinic level and systemic factors are significantly associated with delay in first trimester abortion services. In order to ensure the best physical and emotional outcomes, timeliness of services must improve.

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  • Ladies in waiting: The timeliness of first trimester services in New Zealand

    Silva, M; McNeill, Robert; Ashton, Toni (2010)

    Journal article
    The University of Auckland Library

    Termination of pregnancy (TOP) services are a core service in New Zealand. However, compared to other developed countries, TOP services are accessed significantly later in the first trimester, increasing the risk for complications. The aim of this study is to examine the timeliness of access to first trimester TOP services and establish the length of delay between different points in the care pathway for these services.

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  • Cost-effectiveness of a cervical screening program with human papillomavirus vaccine.

    Sopina, Elizaveta; Ashton, Toni (2011-10)

    Journal article
    The University of Auckland Library

    Recent introduction of a quadrivalent human papillomavirus (HPV) vaccine for girls in New Zealand is expected to decrease the incidence of HPV infection as well as resultant cytological abnormalities and cervical cancer. This may affect the cost-effectiveness of the national cervical screening program by reducing the incidence of lesions detected. This study investigates the cost-effectiveness of the current cervical screening policy with and without the HPV vaccine and compares these results with the cost-effectiveness of a range of other screening strategies.

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  • Decentralizing resource allocation: early experiences with District Health Boards in New Zealand

    Ashton, Toni; Tenbensel, Timothy; Cumming, J; Barnett, P (2008)

    Journal article
    The University of Auckland Library

    Objectives In New Zealand in 2001, a system of purchasing health services by a centralized purchasing agency was replaced by 21 district health boards (DHBs) which are responsible for both providing health services directly and for purchasing services from non-government providers. This paper describes the processes associated with the allocation of health resources in the decentralized system and considers the extent to which four of the government's stated objectives are likely to be achieved. Methods Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis. Results The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decision-making has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts. Conclusions Decentralized decision-making is starting to make some inroads towards achieving some of the government's objectives with respect to resource allocation and purchasing.

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  • Comparing health policy agendas across eleven high income countries: Islands of difference in a sea of similarity

    Tenbensel, Timothy; Eagle, S; Ashton, Toni (2012-06)

    Journal article
    The University of Auckland Library

    Does the way in which health systems are financed influence whether health policymakers are more or less interested in accessible and equitable health services? Are social democratic governments more interested in primary health care reform than conservative governments? Have particular domains of health policy really become more important over the past decade across a range of countries? In this exploratory article, we investigate the similarities and differences in patterns of attention in health policy in eleven high income countries using data from the Health Policy Monitor database from 2003 to 2010. Our study suggests significant 'islands of difference' in an overall 'sea of similarity' between the health policy agendas of the selected countries. The key findings are: (i) that improving population health outcomes is more likely to be on the agenda under tax-based systems and when centre-left parties are dominant in government; (ii) health systems funded through social insurance are more preoccupied with efficiency and cost-containment than tax-funded systems; (iii) the political complexion of governments is not a major factor shaping health policy agendas; and (iv) since 2003 there has been an increasing interest in initiatives that address public health concerns, access and equity, and population health outcomes. © 2012 Elsevier Ireland Ltd.

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  • Biases in describing residents in long-term residential aged care.

    Broad, Joanna; Ashton, Toni; Lumley, Thomas; Boyd, Michal; Kerse, Ngaire; Connolly, Martin (2014-09)

    Journal article
    The University of Auckland Library

    AIM: In New Zealand, no reliable information describes use of long-term residential aged care. Instead, when estimating use, records of government subsidy payments are upscaled to adjust for private payers. This paper assesses consequential bias in reporting use of long-term care and considers the implications. METHODS: Data from OPAL, a census-type survey of residents of aged-care facilities in Auckland in 2008, linked to routinely-collected hospitalisation, mortality and subsidy data from national databases. Demographic, functional and service use characteristics of unsubsidised residents were compared to subsidised. RESULTS: Records of 5961 OPAL residents aged 65+ years were matched with subsidy data; 25% were unsubsidised. In low-level care (51% of all), unsubsidised residents had similar care needs to subsidised residents, but were 1.7 years older on average (p<0.001) with shorter length of stay. In high-level care (41% of all), unsubsidised residents had significantly lower care needs on six different measures and were less likely to die during the follow-up period. Upscaling yields undercounts at all care levels. CONCLUSIONS: National reports derived from current upscaling methods undercount residents. Stratification by region and age group would improve estimates. Age and care needs are misrepresented. Population policies that depend upon upscaled counts should, where possible, ascertain the biases introduced.

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  • Selecting long-term care facilities with high use of acute hospitalisations: issues and options

    Broad, Joanna; Ashton, Toni; Lumley, Thomas; Boyd, Michal; Kerse, Ngaire; Connolly, Martin (2014)

    Journal article
    The University of Auckland Library

    BACKGROUND: This paper considers approaches to the question "Which long-term care facilities have residents with high use of acute hospitalisations?" It compares four methods of identifying long-term care facilities with high use of acute hospitalisations by demonstrating four selection methods, identifies key factors to be resolved when deciding which methods to employ, and discusses their appropriateness for different research questions. METHODS: OPAL was a census-type survey of aged care facilities and residents in Auckland, New Zealand, in 2008. It collected information about facility management and resident demographics, needs and care. Survey records (149 aged care facilities, 6271 residents) were linked to hospital and mortality records routinely assembled by health authorities. The main ranking endpoint was acute hospitalisations for diagnoses that were classified as potentially avoidable. Facilities were ranked using 1) simple event counts per person, 2) event rates per year of resident follow-up, 3) statistical model of rates using four predictors, and 4) change in ranks between methods 2) and 3). A generalized mixed model was used for Method 3 to handle the clustered nature of the data. RESULTS: 3048 potentially avoidable hospitalisations were observed during 22 months' follow-up. The same "top ten" facilities were selected by Methods 1 and 2. The statistical model (Method 3), predicting rates from resident and facility characteristics, ranked facilities differently than these two simple methods. The change-in-ranks method identified a very different set of "top ten" facilities. All methods showed a continuum of use, with no clear distinction between facilities with higher use. CONCLUSION: Choice of selection method should depend upon the purpose of selection. To monitor performance during a period of change, a recent simple rate, count per resident, or even count per bed, may suffice. To find high-use facilities regardless of resident needs, recent history of admissions is highly predictive. To target a few high-use facilities that have high rates after considering facility and resident characteristics, model residuals or a large increase in rank may be preferable.

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  • Reports of the proportion of older people living in long-term care: a cautionary tale from New Zealand

    Broad, Joanna; Ashton, Toni; Lumley, Thomas; Connolly, Martin (2013-06)

    Journal article
    The University of Auckland Library

    OBJECTIVE: Population ageing is driving many countries to review health and social care policies. For many, an important component is residential long-term care (LTC). This study uses New Zealand to ascertain the extent different reports provide consistent and accurate estimates of LTC use. METHODS: We searched for available cross-sectional information about use of LTC by people aged 65 years or over in NZ's population since 1988. In addition, for one geographic region, Auckland, we compared research survey data at three time-points with the nearest census estimates. RESULTS: Fifty-eight national-level estimates (census, subsidy payments and population surveys) were found. Since 2000, estimates of the proportion of older people reportedly living in long-term care ranged from 3.4% to 9.2%. Comparisons with Auckland studies demonstrated improved reporting in the 2006 census. CONCLUSION: Estimates of the proportion of people living in residential LTC varied widely. OECD reports, often used for cross-national comparisons, were particularly inconsistent. IMPLICATIONS: While estimates of the proportion of people living in residential LTC in NZ are inconsistent, improvements are evident in census and subsidy data. Reconciling new data with previous reports prior to publication may reduce variations in reporting. Improved reliability will assist understanding of within-country trends and international comparisons, and better inform decisions shaping health services for older people.

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  • Measuring health system performance: A new approach to accountability and quality improvement in New Zealand.

    Ashton, Toni (2015-04)

    Journal article
    The University of Auckland Library

    In February 2014, the New Zealand Ministry of Health released a new framework for measuring the performance of the New Zealand health system. The two key aims are to strengthen accountability to taxpayers and to lift the performance of the system's component parts using a 'whole-of-system' approach to performance measurement. Development of this new framework - called the Integrated Performance and Incentive Framework (IPIF) - was stimulated by a need for a performance management framework which reflects the health system as a whole, which encourages primary and secondary providers to work towards the same end, and which incorporates the needs and priorities of local communities. Measures within the IPIF will be set at two levels: the system level, where measures are set nationally, and the local district level, where measures which contribute towards the system level indicators will be selected by local health alliances. In the first year, the framework applies only at the system level and only to primary health care services. It will continue to be developed over time and will gradually be extended to cover a wide range of health and disability services. The success of the IPIF in improving health sector performance depends crucially on the willingness of health sector personnel to engage closely with the measurement process.

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