Healthcare Like many countries around the world, Australia has implemented policies associated with healthcare reform. Healthcare reform is an important issue because of the number of people that are affected by the decisions made by government and healthcare providers. Of the most concern is the drastic increase in the number of elderly patients that is expected over the next few decades.

With these things understood, the Australian government has undergone a process of reforms designed to address the needs of the population. These reforms address concerns related to both the private and public aspects of the Australian healthcare sector that often work together to provide the population with care. Currently in Australia,

"Primary health care in Australia is delivered through a mix of Commonwealth, state and territory government funding and private funding, and publicly and privately delivered services. While many primary health care services are delivered through privately provided general practice, supported by patient access to Medicare rebates, it is recognised that a range of other programs have developed to address some service gaps as they have emerged (Primary Healthcare Reform in Australia)."

Outsourcing or managing out is one of the programs that has emerged as a result of the increases in demand for healthcare and the patterns associated with demands for healthcare in the future. Outsourcing is defined as "the strategic use of efficient third-party providers to perform essential functions traditionally handled internally (in-sourcing)," and it is generally used to cut costs, save time, and increase flexibility for projects and services (Le & McManamey 2005). Outsourcing is a strategy that has long been associated with the business community. However, in recent years healthcare systems throughout the world have begun to implement outsourcing policies. As a result, "managing out" -- which represents a shift toward getting needs met at least in part by the private sector through contracting out and other approaches that leverage private sector resources -- has become a common approach in many public sector services. The public sector and the private sector are thus sharing the responsibility for accomplishing certain government services, including healthcare.

National Health Reform in Australia has been a significant undertaking. In fact it is the most significant Health care change that has occurred since the country introduced the Medicare system (National Health Reform). Before the health care reform was implemented New South Wales (NSW) was composed of 8 Area Health Services, that were inclusive of Northern Sydney Central Coast Health. Beginning in the year 2009 this Area Health Service implemented an Area-wide Visiting Medical Officer (VMO) Quinquennium Process. A VMO is a specialist doctor who is permitted to provide services in a public hospital to public patients. VMO's can also be a specialist doctor who practices privately. VMO's are different from salaried medical officers because they are not hospital employees but instead they are classified as independent contractors. Independent contracting is the form of outsourcing under which many VMOs are classified. Additionally, VMOs "may be appointed to any of the medical specialties including anaesthesia, dermatology, emergency medicine, intensive care, obstetrics and gynaecology, ophthalmology, pathology, adult medicine, paediatrics, occupational medicine, public health, rehabilitation medicine, psychiatry, radiology, radiation oncology and surgery ("Visiting Medical Officers")."

VMO's are classified as fellows who have "completed all specialists training, eligible to work as a specialist ("Position classification descriptions")." In addition VMOs may be considered "contractors," in that they are not employees of the organization. The reform is also designed to reappoint VMOs to Hospitals within the Area. The process involves a required Medical and Dental Appointments Advisory Committee for approval.

In addition as a result of the National Health Reform Agreement the former Northern Sydney central Coast Health now consists of two separate districts: the Northern Sydney Local Health District and the Central Coast Local Health District. Accountability is a major aspect of the reappointment process. For instance, the Chief Executives reported to the Director-General. This governance structure ensures that there is accountability at every level of the process. Accountability assist in making certain that everyone involved in the process are held accountable for their actions and when individuals are held accountable for their actions they are often more likely to make good decisions that will be of benefit to the process. During times of reform such accountability also assists in finding both the weaknesses and strengths that may be present so that they can be altered in a manner that is beneficial to both medical professionals and patients. Additionally as a result of the new National Health...

As such the staff will have to be divided so that the to support the 2 Local Health Districts will be adequately supported because there is a lack of resources. (At the current time the unit remains a part of Northern Sydney LHD.
A new Quinquennium was established for the years that span 2009 until 2014. Under this current appointment process, the reappointments were managed by Workforce Development ("Quinquennium-extension to 2009 and new Quinquennium to 2014"). There are a total of six phases and deadlines associated with the reappointment process. These phases and deadlines are as follows:

1. Establish the number of VMOs that are needed prior to advertising the positions. The people responsible for determining these numbers are Clinical Network Directors, Directors of Medical Services and Director Medical Workforce. During this phase it must also be the qualifications for each group must be determined and approval must be gained for recruitment ("Quinquennium-extension to 2009 and new Quinquennium to 2014").

2. Advertisements for VMOs must be published. Recruitment services are responsible for ensuring that the advertisements appear.

3. Interview and select the VMOs best suited for the available positions.

4. Refer the appointments to MDAAC. MDAAC then has the responsibility of checking and approving the appointments.

5. Contracts are drafted and sent to the selected VMOs.

6. Contracts are received and all papers are finalized. ("Quinquennium-extension to 2009 and new Quinquennium to 2014")

The VMO process resulted in the appointment of 700 Visiting Medical Officers (Hi Nel, Using the former organization configuration (NSCCAHS approx 15,163 headcount) VMO's make up approx 5.3% of the workforce (Headcount, 700 in Quinquennium). The appointment of these VMOs is based on their abilities as specialist and their track records in their particular fields. Reappointment to the various facilities is often based on past performance which is recorded (level 1 and level 2 performance reviews) and can be evaluated as a condition under which a physician can be reappointed.

The challenges and complexity for management

The use of outsourcing in the form of VMO's is essential to meeting the needs of Australians in both the present and the future. However the Northern Sydney Local Health District faces many challenges associated with the Visiting Medical Officer (VMO) Quinquennium (reappointment) Process. One of the primary challenges is associated with ensuring that the quality of service is the same at all of the facilities for which the Northern Sydney Local Health District is responsible. This is a management challenge that must be carefully considered. One of the ways in which this challenge can be overcome is through periodic performance reports that are an aspect of the healthcare reform package. The purpose of the performance reports is to ensure that the Visiting Medical Officers are performing in a manner consistent with the expectations established by NSW Health. According to NSW Health all Public health organizations must conduct a 'Level 1' performance review each year for all specialist VMOs contracting with the organization. In addition, a level 2 performance review must also take place during the penultimate year of any VMO appointment in which the physician has a term of three years or more.

NSW Health also explains the mandates associated with appointing a specialist VMO with an existing appointment not including an announcement of such an appointment under the following circumstances:

"(a) the role and responsibilities of the VMO remains largely unchanged since he or she was originally appointed; (b) there has been a Level 2 review of the VMO in the penultimate year of the term of his or her appointment, and the performance had been found to be such as to warrant renewal without advertisement ("Visiting Medical Officer (VMO) Performance Review Arrangements")."

The level 1 performance review is to be downloaded from the internet in PDF format. The review contains two sections. The first section or Part A is a self-assessment section and part B of the review is completed by the supervisor who oversees the VMO ("Visiting Medical Officer (VMO) Performance Review Arrangements"). Once the review is assessed and the findings are satisfactory no further action will be taken. However if there are any unsatisfactory elements of the review or additional information is needed concerning the VMO further action might be taken ("Visiting Medical Officer (VMO) Performance Review Arrangements"). In most cases such actions might consist of a meeting or another interview of the VMO.

The level 2 performance review is more complicated than the level 2 review. According to a published report on the policies that govern performance reviews,

"The Level 2 process involves the…