The Centre for Policy Development has published a fascinating series of short articles by people with huge expertise on the Australian health system. There seems to be agreement on a lot of basic propositions: we need a system that works well for those with chronic illnesses; we need more distance between health care delivery and daily politics; we need one level of government (generally, the Commonwealth) to fund public health care; we need to make it easier for people to understand their entitlements and exposures and simplify the rabbit warren of subsidies and protections that has built up over the years for various categories of providers; we need to figure out how to do teamwork properly so that care can be safer and more reliable.
Thanks to Todd Hansson
It seems that we don’t lack for good ideas, and even a degree of consensus, at least on what challenges we ought to take on. So, why isn’t there any sense that the changes we need are happening? Perhaps what we really need is a vision for how to get from here to there. Here’s my understanding of three essential requirements for change to happen, and my imagining of how they might occur.
First requirement: Chaos and opportunity
Neal Blewett reminds us that Medibank would probably never have been approved if it hadn’t been for the joint sitting of the houses of parliament (back when the government didn’t control the Senate) after the double dissolution of 1974. Where might we get a circuit-breaker these days? Hopefully not from a bird flu pandemic, but maybe it will take a major public health crisis to dislodge some of the enduring structural problems that are such an embuggerance (a technical term of military origin, which is used to describe factors that are supposed to support or assist in the achievement of a goal, but actually get in the way) to change. It won’t come from COAG alone — not when all the people with seats at the table have a stake in the system as it is. And it won’t come from the learned colleges alone (including my own), for which the same applies.
Second requirement: Technical method
The second essential element is some kind of technology or method that can give us new tools — and hence open up new possibilities, even if the possibilities were always there, just waiting. Portable PCR technology applied to pathology testing was such a breakthrough. It enabled Nganampa Health Council, a pioneer in this area, to bring acceptable screening for STIs to the Anangu people. It seems that this technology was the final piece of the puzzle that enabled all the good planning, good evidence and good will of Nganampa and its staff to achieve their long-held goals in this area, with dramatic impact for the people’s health.
What might the critical technical development for fixing our health system look like? Maybe something like the use of ‘lean thinking’ at Flinders Medical Centre — a method borrowed from Toyota and operations research in the manufacturing industries — will be part of the solution for hospitals. The ‘Maggie’ project at John Hunter Hospital in Newcastle is another example. The exciting thing about these developments is that finally something looks like it might work, after what feels like at least 20 years of hand-waving by people like me in the executive suites of hospitals – people saying ‘there has to be a better way of organising’ but lacking the hands-on knowledge to figure out what it is. With these techniques, the drive for change has finally come to focus on the very practical, material problems that bedevil the best efforts of clinical and support staff to deliver the right care at the right time in the right order. Maybe the rest of us need to look and learn, and only when the real requirements for good operations are clear, start trying to shift the structures and policies so that they align with good practice.
But even if this works for hospitals, what about primary health care? Hospitals might be big and hungry and slow to move, but at least they do control what happens during a hospital stay, more or less. No-one in primary care gets to manage the whole process, and if it works, it does so in spite of the barriers and eligibility hurdles and differential delays and financial border posts that providers and clients spend so much time negotiating. While the structural nature of the problems are even clearer here, maybe the same principle applies: we need a working model on the ground, and we need to look and learn.
Coordinated Care Trials have been conducted in which care coordinators worked with patients (often those with chronic diseases) to better manage their illnesses and to move care out of hospital and into the community. Part of the design was that ‘the money followed the patient’ through pooling of Commonwealth and state funding.Continuing the learning from these may be part of the answer, but primary health care is much more than the management of chronic diseases.
It gets even more complicated when we consider the challenge of healthy public policy. No-one owns this territory, and it is more deeply contested than the question of who really runs hospitals. But here too, it seems to me, new insights and techniques (like knowledge of how to support all parents – good, middling and befuddled – to give their kids a reasonable start) tends to open up new possibilities for good policy-making and better equity across social divides, even if we have to wait for long term benefits.
Third requirement: leadership in some direction
Martin Luther King wasn’t a saint until after he died. While he lived, I have no doubt that he was a mortal person, occasionally getting it wrong, or failing sometimes to make the heroic effort that was required day after day. We can’t rely on finding a hero to lead us, rather we have to hope that all sorts of good people will exercise leadership in their own spheres of influence to enable new ideas to be tested, and then implemented. The current reaction on some sides to suggestions that the borders between professions might move a little (so that, for example, nurse practitioners might do just a little prescribing of drugs) is not a good sign in this regard.
What I’m looking for is not a ‘great man’, or even a ‘great woman’, but a bit of loosening up. If the stakeholders could please relax the stranglehold a little, changes that haven’t yet been dreamed of might be possible. I think that’s the single most important thing that everyone with a capacity for leadership could pursue. Good things happen when, for example, an experienced psychiatrist rethinks how to deal with mental health crises in the emergency department, or a skilled bush nurse extends her role, or when leaders are encouraged to think about health rather than opinion polls.
What might the journey look like?
I can imagine a pathway like this: a pandemic means that the already severe workforce shortage starts to devour the capacity of the health system. In desperation, health professionals start experimenting with new ways of delivering care. There are some mistakes, but old disciplines die hard and they are corrected. Staff with experience in ‘leaning’ (finding the most straightforward way to organize care) teach others and the method spreads fast through necessity. Staff in health departments and universities help where they can, and also learn from the new practices.
When the crisis period is over, the leaders who have emerged refuse to let go of a better way of doing things. Nothing is the same again at the point of care. In the offices of government departments, the strong who are still standing begin to analyse the implications and apply those ideas to the way that health care is funded and regulated. Academics redesign professional training programs, in such a way that new graduates identify strongly as members of the health team as well as being proud of their specialisation and its place in the team effort. Clinical and management leaders have learned that the experimentation must continue, and find ways to be comfortable with an empowered workforce, while still exercising their authority to coordinate and lead.
Almost certainly, this precise scenario won’t happen. But whatever does develop, it won’t be good unless we learn what the evidence already tells us: skilled professionals need to find meaningful methods of working together to improve the way that health care is delivered; and to keep experimenting to resolve each new problem as it emerges. That is my most treasured health vision.