Alison Barrett writes:
The Federal Government has been urged to consider appointing an Aboriginal or Torres Strait Islander health professional to succeed Professor Brendan Murphy, who retires as secretary of the Department of Health and Aged Care on 6 July.
This “would be a great opportunity to highlight our communities’ excellence and start to redress the significant lack of First Nations leaders at the top levels of the Australian Public Service”, a Lowitja Institute spokesperson told Croakey.
“Currently, Aboriginal and Torres Strait Islander people make up only a handful of the executive agencies’ and statutory authorities’ CEOs, and none of the Department secretaries. Yet we have so many incredibly impressive leaders across public policy fields – perhaps none more so than the health and wellbeing sector.”
Murphy’s retirement provides opportunities for re-imagining the role and its scope, including how to help achieve much-needed structural reform in health and aged care, according to Australian health leaders surveyed by Croakey.
A recent narrative review published in The Medical Journal of Australia has identified many of the challenges, including a lack of integrated health financing and a fragmented, complex healthcare system, reform proposals for the Pharmaceutical Benefits Scheme, out-of-pocket health-related costs, public subsidies for private health insurance and inequity.
The review said “one of the major shortcomings of the Australian universal healthcare system is that it does not achieve the same health outcomes for Indigenous and non-Indigenous Australians”.
Croakey surveyed health leaders about the qualities they’d like to see in the next Secretary of the Department of Health and Aged Care, the type of expertise required, what their priorities should be, and the risks and opportunities ahead, as well as providing some advice for the interview panel.
This is the first article in a series reporting on the survey findings.
Responses suggested the new Secretary faces a big agenda, in delivering on recommendations from the Aged Care Royal Commission, strengthening primary healthcare and the health workforce, implementing reform priorities from the National Agreement on Closing the Gap and committing to reducing emissions in the health sector.
The next Secretary should be brave, evidence-informed, and committed to social equity, values-based healthcare and culturally safe workplaces, the survey found.
Intellectual horsepower required
Charles Maskell-Knight, a former senior public servant in the Department of Health
I worked in the Department of Health under half a dozen Secretaries – one was outstanding, four were highly competent, and one was terrible.
Qualities for success
First, intellectual horsepower and intellectual curiosity. Health and aged care are incredibly complicated, and if somebody doesn’t know the issues before they start, they need to be able to get across them quickly. And they need to have the antennae to know when to ask the next question, when to delve a little bit further into a new issue, because that may be where the opportunities (or threats) lie.
Second, loyalty: to their staff, to the public service, and to the Minister.
I and most of my colleagues would always go the extra mile for one Secretary, because we knew they had our backs and valued our efforts. But if you know the Secretary is not backing you in disputes with the Minister, the MO, or powerful lobby groups, why bother speaking truth to power? And loyalty to the Minister means frank advice, not sycophancy.
Third, management ability. The department is too large for one person to manage, so a good Secretary needs to pick good subordinates and delegate effectively, not micromanage. They should be the coach, not the star player.
The outstanding Secretary scored 3/3 on this list, the competent ones 2 to 2.5/3, and the terrible one would have struggled to get to 1/3.
In terms of expertise, I think previous experience in and knowledge of health and aged care policy is an advantage, but need not be a prerequisite. But a health-naive appointee should make sure they have exceptionally competent deputies, and seek to establish an unofficial group of outside advisers until they are sure they are up to speed on technical issues.
The most important priority for the next Secretary should be to re-establish the Department’s policy knowledge and expertise. There are several elements to this.
The first is structural and staffing stability. A new Secretary should stop redesigning the department and regrouping functions and live with the imperfections of the current structure (bearing in mind that a new structure will also be imperfect). They should tell senior staff that they will be in post for a minimum of three years, as this is the time needed to build a good team, really get across the policy issues, and deliver some results.
The second is staff development. When I started in the department it contracted with a university to run in-house health system education. As a result most junior and mid-level staff (APS5 to EL2) had a sound idea of salient health policy and program delivery issues across the portfolio.
When I left, the training budget was cut to the point only one staff member out of a branch of 20 could attend a one-day external seminar once a year, as long as it didn’t involve travel. The department was full of people with no idea about how other parts of the system worked, meaning their work often overlooked important consequences for other parts of the health system. A new Secretary needs to invest in health system training.
From the Government’s perspective, a good appointment will be an opportunity to lift substantially the quality of disinterested advice on the major health and aged care policy challenges it faces.
The risk of a poor appointment is that the Department of Health will continue to be nothing but a project manager for expensive consultants doing the policy work that should be done in-house.
I’m not sure that there will be a selection panel. But if there is, it should ask all candidates from within the APS to provide a copy of the latest staff survey results for the areas they manage. Any deputy secretary who cannot establish a productive working culture within their area of responsibility is unlikely to be able to do so across an entire department.
Spokesperson from the Lowitja Institute
To accelerate progress against the National Agreement on Closing the Gap (National Agreement) – particularly the Priority Reforms – it will be critical for the next Secretary to demonstrate a genuine commitment to transforming the way the Commonwealth Government goes about supporting Aboriginal and Torres Strait Islander peoples’ health. In terms of self-determination, working in partnership, and eradicating systemic racism, it’s time to stop tinkering around the edges.
Experience working in real partnership with Aboriginal and Torres Strait Islander communities and our community-controlled health organisations – not consultation, partnership – is crucial. We need to be the leaders of the policy and research agenda when it comes to our health and wellbeing, and a Secretary who takes the same top-down approach that has existed for decades won’t enable that.
Initiatives under both the National Agreement and the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 desperately need to be funded. In particular, our Aboriginal and Torres Strait Islander community-controlled healthcare organisations must be able to scale up their services so that mob aren’t waiting as long or travelling as far to access care, especially preventative care.
We also need to see more Aboriginal and Torres Strait Islander-led research and action on the social, cultural and environmental determinants of health as a key priority, including the impact of climate change on the health of our peoples.
If the next Secretary moves decisively on the National Agreement’s Priority Reforms and is led by the Aboriginal and Torres Strait Islander experts in those decisions, this could be a pivotal opportunity to change the trajectory on so many of the Closing the Gap socioeconomic targets – life expectancy, healthy birthweights, suicide prevention.
If the next Secretary is inclined towards the business-as-usual approach – a focus on measuring Aboriginal and Torres Strait Islander people and communities for perceived dysfunction, rather than empowering us to lead those transformative changes – it’s a sad certainty that we will continue to see poor progress against the Closing the Gap targets.
Tips for the interview panel
It will be important to get an accurate picture of candidates’ commitments to the Closing the Gap framework, including each of the four Priority Reforms and how they see those as being most effectively carried out. Exploring candidates’ intentions for developing strong relationships with Aboriginal and Torres Strait Islander leadership structures, like the National Health Leadership Forum and the Coalition of Peaks, would also be useful.
Who would you most like to see in that position?
Appointing an Aboriginal or Torres Strait Islander health professional to the role would be a great opportunity to highlight our communities’ excellence and start to redress the significant lack of First Nations leaders at the top levels of the Australian Public Service.
Currently, Aboriginal and Torres Strait Islander people make up only a handful of the executive agencies’ and statutory authorities’ CEOs, and none of the Department secretaries. Yet we have so many incredibly impressive leaders across public policy fields – perhaps none more so than the health and wellbeing sector.
A critical appointment
Professor Linda Slack-Smith, social epidemiologist at the University of Western Australia
Evidence they are driven by strong values aligned with public health including social justice, equity, integrity. They need to be brave, have insight, vision.Expertise
Ability to bring together wise counsel – to advise them.
Clear understanding of both empirical and contextual evidence (have available and critically examine quantitative and qualitative evidence).
An understanding of why we need detailed openly available high-quality data on health matters.
Ability to work in ways that bring key stakeholders together promoting intercultural and intersectoral approaches.
Substantially increase focus on prevention in health – this is not just about health anymore (although critically important for health) but about our broader approaches as a nation to matters such as supply chains for food and climate change.
Concurrent investment in delivery and research in quality primary healthcare and public health.
Ensure an outstanding communication strategy with a health literacy focus.
Systems for evaluation and feedback that are more current than doing reviews after the fact that take years.
Promote availability, affordability and adoption of healthy food.
Ensuring everyone has access to basic needs, medical care, dental care.
This is an extremely important appointment for the Government.
Adjunct Professor Kylie Ward, CEO Australian College of Nursing
Qualities we want to see in our next Secretary of Health and Aged Care include someone committed to social equity, and the delivery of values-based healthcare. To achieve this for all Australians they will need to be a strong, inclusive and effective communicator.
Well regarded as someone committed to ensuring all consumers have access and equity to quality healthcare will require them to have integrity and courage to withstand lobbying from traditional and paternalistic stakeholders.
The Australian College of Nursing has a strong relationship with the Department of Health and the current Secretary, and we would be looking to see that the person appointed has this same respect for the nursing profession, being the largest clinical profession in the country.
The Secretary also needs to be able to engage with stakeholders including NGOs and NFPs to understand the stressors in the system we face each day from both a workforce and the consumer perspective. The co-design of solutions is the best use and value of taxpayers’ dollars.
The role will require the new Secretary to hit the ground running, so while expertise and qualifications are always important, what is key is actually a deep understanding of the inner workings of the health system and the people it serves.
There are growing sectors of the healthcare consumer population that are underserviced, poorly serviced or have delayed access to healthcare and we need the Secretary to understand this so that they can work with the sector to make sure these Australians do not slip through the cracks. Our white paper on Optimising Advance Practice Nursing will give them a strong understanding of the problem.
ACN would like to see the Secretary work towards collaborative service models where nurses, medical practitioners, pharmacists and allied health professionals work to their full scopes of practice and deliver safe, equitable, accessible health services across Australia.
Education and research funding on the design and evaluation of innovative practice initiatives to address the health needs of communities are urgently needed. Nurses make a significant contribution to the management of care and treatment for people living with chronic disease and multimorbidity. The visibility of nurse-led innovations is low; good practice cannot be shared or acknowledged without dissemination of the outcomes.
There has been a well-needed shift in the latest government towards acknowledging the impacts of climate change. ACN advocates for the leadership of the health profession in reducing emissions. It is imperative that the next Secretary understand the importance of committing to emissions reduction in the sector.
ACN would like to see a system redesign in community and primary healthcare to ensure a sustainable health care system for all Australians into the future.
Community and primary healthcare applies a social model of health care that addresses the health needs of individuals and communities while considering the social, economic and environmental factors impacting their health.
This person-centred focus is attributed to all areas of nursing practice and provides an essential process of collaboration and partnership that takes place in the successful planning and delivery of care outside of the acute health care setting.
The risk is that if you get it wrong, we will continue to see dedicated people leave healthcare roles and risk healthcare becoming unaffordable and inaccessible. We need reforms that allow all clinicians to work to top of scope, and all consumers to access care in a timely and affordable way, irrespective of postcode.
The new Secretary must understand that there are some Australians who are uniquely disadvantaged and at greater risk of poor health outcomes, including Aboriginal and Torres Strait Islander peoples, those from culturally and linguistically diverse backgrounds, those in the LGBTQIA+ community and those with poor health literacy and limited financial resources.
Tips for interview panel
ACN would like to see adequate representation of the stakeholders that make up the Australian healthcare system. This includes a representative of the nursing profession. We need a future-focused Secretary that can consider care beyond 2030 and that requires panel members who are innovative, strategic and committed to population and preventative healthcare.
Fresh face needed
Spokesperson for the National Health Leadership Forum
The NHLF would like a Secretary that is a good listener and someone who is prepared to shape advice to Government based on the information from those with lived experience on issues concerned and from those that work in the area, rather than relying on desktop only research. Additionally, we want a Secretary who is willing to name racism and embark on creating a culturally safe workplace. This would require rolling out cultural safety across the Department, and more broadly utilise cultural safety as a change mechanism within the organisation and as importantly in the way it does its business, i.e. policy design and program development, including accountability within contracts and funding agreements.
It would be good to have someone that has outside of the APS or state government experience, someone who has worked in some capacity in the health sector would be good. Someone that has an idea of what actually happens on the ground, they don’t need to have been high level at the time but someone with work experience outside of major bureaucracies. No former political advisor, they’d think too much like a politician rather than what actually needs to be done.
The NHLF would like to see the health plan implementation with the right accountability mechanisms in place to be a priority. We also want to someone in the Secretary role who sees the opportunities of the priority reforms in the National Agreement on Closing the Gap and will be driven by them.
To recruit someone with fresh ideas and one that isn’t focused on maintaining the status quo, someone who understands how socioeconomic disadvantage can shape someone’s health, and how experiences of discrimination/racism may influence how someone interacts with the health system. Someone who hasn’t been in Canberra for long and understands how Australians outside of the Melbourne-Canberra-Sydney triangle lives and what barriers to accessing to good health care actually means.
If they recruit from the same pool of current bureaucrats then we will not get the reforms sought from the National Agreement on Closing the Gap. They will keep doing the same thing.
Tips for the interview panel
Be prepared to take a risk and not recruit from the same small pool of senior Commonwealth Bureaucrats or from the Triangle, be brave and look for a fresh face.
Bold reformer needed
Bold, brave and willing to challenge the status quo. We are at a critical juncture in the health and aged care landscape, and we have a unique opportunity for reform.
They will need a deep commitment to listening to the lived experiences of people accessing our health and aged care system and ensuring that those experiences drive the reform agenda.
A collaborative approach that works across Departmental and jurisdictional boundaries, including the State and Territory divide. The issues faced within the health and aged care systems cannot be solved without looking at the wider social determinants of these issues.
Re-imagining our health system to focus on prevention to improve health outcomes and make the system sustainable long into the future. To do this they will need to reform our primary care system, starting with implementing the Medicare Taskforce recommendations. The National Health Reform Agreement will need to be overhauled to move care out of hospitals, into communities and focus on true early intervention, not just hospital diversion and acute care settings.
We also need to ensure that the Aged Care Royal Commission recommendations are fully implemented and are underpinned by effective and sustainable funding.
To pick the leader who can unite the Federal and State and Territory governments in a bold reform agenda.
Tips for the interview panel
Include community, consumer, and workforce representatives in your panel. Those who have lived experience of the health and aged care system should play a key role in deciding who will lead the systems they are part of.
It’s impossible to name a candidate! We would love to see someone who can bring a different lens to the challenges we face, with direct experiences in the front-line of our health and aged care system, whether as a consumer or worker.
Stay tuned for more perspectives in the next article in this series.
See Croakey’s extensive archive of articles on health reform.