Lessons from an integrated care simulation – and charting some future directions for the health system

Jennifer Doggett and Marie McInerney report:

What happens when you get about 85 health leaders into a room to workshop major health policy initiatives?

That was the question the Australian Healthcare and Hospitals Association (AHHA) wanted to test at a recent Integrated Care Simulation, which aimed to turn Old Parliament House in Canberra into a “realistic but stage-managed” environment for three major potential health policy initiatives:

1. the introduction of bundled care packages for people with chronic diseases
2. a role for private health insurers in the financing of primary care services
3. the formation of Primary Health Networks.

There was surely something significant to the timing and location: staged where universal health care was born in Australia under the leadership of former Prime Minister Gough Whitlam and in the week that he died, aged 98. Floral tributes to him lay at the front door, including a wreath laid by the current Labor parliamentary team, and a condolence book was open in the nearby Members Bar.

No doubt Whitlam would have appreciated the robust debate and spirited discussions about the future of our health system and our core community values that took place over the course of the simulation.

Why a simulation?
Policy simulations are not a common methodology used in Australia to explore changes to our health system.

This is unfortunate as major health policy changes often have wide-ranging impacts on our community and on the lives of individuals.  However, there is often little understanding among politicians and policy makers of the broad ranging effects of policy changes, often reaching far beyond the health sector, and little effort put into looking at the complexities of how they would work in practice.

One recent example is the $7 GP co-payment, which was proposed by the Government without any attempt to explore how it would impact upon disadvantaged groups in the community and potentially result in higher health and social costs overall.

Health systems are complex and made up of an interconnected set of relationships between individuals, organisations and groups, all of which have unique aims, motivations, beliefs and cultures.  Because of this complexity, it is very difficult to assess the impact of a major health policy change through unilateral research, modelling or consultation processes.

A simulation is a way of modelling changes within a complex system in a way that reflects the inter-dependent relationships between all components.

Admittedly, simulations present some formidable logistical challenges – getting 85 health leaders together in a room at the one time is hard enough, without the added difficulty of marshalling them into groups to role play possible health policy scenarios with enough detail to be realistic and straightforward enough to be sufficiently explored in about an hour and a half.

Of course simulations can never be a perfect model for reality, and it’s important to understand their limitations, but they can provide substantially more information than theoretical research or modelling which just looks at one aspect of a proposed change.

In particular, simulations can help understand how the different elements of the health system work (or don’t work) together under different conditions, a crucial pre-requisite for improving the coordination and integration of care and increasing the efficiency of resource allocation.

How it worked
This was an early comment from a participant:

“I’m really looking forward to it, there’s not often the opportunity to do this sort of thing, to explore issues with an intellectual challenge. It’s different from just going to a conference and hearing from others. You have to test yourself. I’ll be interested to find out why the scenarios were chosen.”

The groups were divided into three teams, with most participants playing roles very similar to their real life roles. Each team tried to include representation of the following roles:

• Commonwealth Department of Health
• State Department of Health
• Primary health organisation (Medicare Local)
• Local Hospital Network
• GP/Clinician
• Specialist
• Nurse/Allied health provider
• Academic/researcher
• Community health service
• Ehealth/health technology expert
• Private health insurer
• Private health business (e.g. pharma)
• Political office
• Patient.

The AHHA acknowledged the list did not include representatives from some key areas of the health system such as Indigenous health and aged care in particular.

It was perhaps portentous, given the feedback on the day, that the patient came last in this list, though the roles were played with great gusto by Dewi-Inala Zukefi (Consumers Health Forum), Patrick Tobin (Catholic Health Australia) and Priyanka Rai (Alzheimer’s Australia).

Tobin introduced himself to one group as: “not well, very depressed, drug and alcohol issues, overweight, lives out in the sticks, doesn’t like doctors, doesn’t interact much with the health system, now has a very bad toothache. And doesn’t have PHI”.

That made him, he said, “probably someone the health system does not relate to that well”. Talking later about silos in the system, Tobin noted with some irony that it’s the patient “who really sees the health system in its totality”.

Also on hand through the scenarios was a data team (who delighted one team with the promise – “no worries” – they would be able to come up with national system of indicators, ability to benchmark and measure performance) and roving ‘media’, who were used by patients and Minister but few others.

The teams were led by three people with extensive health policy (and politics) experience.  Eastern Sydney Medicare Local CEO Tim Smyth lead Team A, Terry Barnes, a former advisor to Tony Abbott when he was health minister (and the author of the original submission that sparked the Federal Government’s proposal to introduce a $7 GP copayment) lead Team B and Carol Bennett, former Consumers Health Forum of Australia CEO, now an independent consultant, lead Team C.

A very dynamic Minister (Grattan Health Program Director Dr Stephen Duckett) emerged unscripted, with a range of frequent and rapid announcements.

As one of his group observed: “Just as we thought we’d get on top of something, the Minister would announce something else, which threw us out sometimes….(But) if he hadn’t, we’d probably still be sitting there debating what coordinated care and integrated care actually meant.”

The AHHA’s understanding of the term, by the way, comes from the World Health Organisation:

 ‘the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money’.

The original idea was to try to act out the three scenarios through three different timelines: over the next three months, within 12 months and over the coming three years, but, with about 90 minutes for each scenario, it proved a bit ambitious.

‘Chance cards’ were also available as a disruptive tool for team leaders to liven up the role-playing, and these included such things as: opportunistic injections of funds from government, emerging regional workforce shortages, a catastrophic bushfire, and closure of a major private hospital.

Analysis by Jennifer Doggett

Process

Perhaps because simulation is an unusual methodology, many of the participants seemed unsure at first of how they were supposed to behave. Many people stood around uncertain of the process and waiting for someone to come and tell them what to do.

The main focus for much of the time was on discussing the pros and cons of the policy with other stakeholders. The discussions were much more on a theoretical than a practical level, i.e. detailed critiques of the policy rather than practical suggestions for how it could be improved.

To some extent this mirrors reality where there are no ‘rules’ for how best to influence policy.  It can appear sometimes that health stakeholder groups, in particular, health professional and provider groups, are most focussed on discussing the flaws of specific policies with each other rather than putting their efforts into changing the policy or trying to directly influence policy makers.

There were a number of comments about how rushed the process was and how they did not have enough time to respond properly to the brief. This is another example of how the simulation can mirror reality although this could backfire if people found it too frustrating and decided not to contribute.

Lesson: health groups/stakeholders might benefit from specific education and training focussed on the policy development process and how to maximise influence. In particular, they could benefit from exploring issues around how to influence government when also receiving government funding.

Lack of innovation

Overall, there was a lack of innovation in the response to the policy scenarios.

Most of the responses were predictable and did not involve any ‘out of the box’ thinking. For example, in looking at funding for care coordinators there was no suggestion made to pool all available funding or to deliver care in a different way, the proposal was based around paying separately for an additional service (care coordinator) on top of all the other services separately provided and paid for.

Similarly, in approaching the other two scenarios, the proposed responses left most of the basic system of primary health care intact and did not suggest major changes to professional roles and responsibilities, funding systems, fee for service, physical delivery of care and the role of consumers.

The most innovative member of Group A was the IT expert who managed to find a new consultancy opportunity in every Scenario and policy option! The team leader made the interesting observation that the group “started with the system we have rather than the one we could have”.

Lesson: Perhaps the briefing for the simulation could have been more explicit in seeking innovative views so participants may have felt more confident proposing more radical changes.

Alternatively, the outcomes may reflect the reality of the health system, i.e. that there are not many innovative ideas being proposed, either because there aren’t many around or there is no perceived support for innovation within the health system.

Consumers not engaged

In all three scenarios, consumers and consumer needs were discussed extensively. However, overall there was little consultation with the actual consumer representative.

When the consumer advocate in one scenario forced her way into discussions, she was accepted but in one instance where she did not do that, she was almost completely ignored.  In fact, the final proposal was based on an assumption about her underlying condition, which turned out to be completely false.

Where consumer advocacy groups were consulted, it was not clear how and to what extent they were representing actual consumers.

One team leader observed the group had a “very bolshy” consumer representative, who was very vocal about what a new bundled care scenario would mean for her but she was sidelined by vested interests concerned about how the system changes affect them.

Another was struck how, in two scenarios, the patient was “listened to but not necessarily at the centre of the final thing”.

Lesson: consumer input does not happen by accident! It is important that consumer input is explicitly sought and not just assumed if all the stakeholders talk positively about consumers.

Also, there is no, single, method that is always appropriate for engaging consumers, often multiple methods need to be used.  Consumer advocacy groups play an important role but are not representative of every individual consumer.

GPs not consulted

Similarly, while the role of GPs was actively discussed, there was not a great deal of direct GP consultation.

The organisations that claimed to represent GPs were not necessarily engaged with all GPs at the grass roots and there were difficulties in getting these GPs involved. A number of policy proposals were made that would directly impact upon GPs without directly consulting with them to obtain their views.

As the Commonwealth left one table discussing the bundled care scenario to talk to the GPs, the private health insurer warned: ‘Don’t talk to the union, talk to the College.”

Lesson: GPs are an essential component of the primary health care system but they are a diverse group and no single method of consultation is going to work for all of them.

Some are actively disengaged from mainstream groups and need a different approach in order for them to feel involved.

Lack of lobbying and media

Overall, there was a lack of lobbying of Ministers and other politicians by the group and a lack of effort put into trying to change the policies that had been proposed.

Initially, there seemed to be an acceptance that the policies proposed by Government were set in stone, despite the fact that the Minister himself changed the details of them a few times. This changed over the course of the Simulation and in the 3rd Scenario participants actively lobbied for a policy change.

There was also little use of the media to influence government and stakeholder opinion and/or to achieve policy changes.

Lesson: the lack of pro-active lobbying and media use may reflect a lack of understanding of the parameters of the Simulation.

However, it may also reflect a lack of understanding of how to seek and achieve influence within the health sector.

More education and training around lobbying, government relations, policy making and the role of the media may assist health groups in increasing their influence over the policy making process.

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Some of the key quotes from discussions (these are all anonymous)

“Andrew Southcott opened the day, saying as all Ministers of both stripes do, that ‘we have the best (or third best) system in the world because we live the longest’. But if we factor in equity, we don’t….Is life expectancy the only thing we want or are there issues around equity, choice, respect for the individual – and which is more important. A lot of the less productive discussions we had today you could trace back to people not agreeing where they want this whole thing to end us up.”

“Consumer centred care does not always mean ‘more, more, more’. Sometimes it is: ‘I don’t want to be on the conveyer belt, I’m happy to have community support.'”

Primary health care organisation: “I might be run out of town by my peers, but I do see great opportunities to explore how to bring (public, private) together. The split can really get in the way for patients.”

On integration: “This sounds like we’re trying to achieve funding savings rather than health outcomes. Let’s start from the patient rather than who is in the business.”

“Let’s not focus on funding, let’s focus on outcomes and systems reform.”

“At the moment, funding is driving decision making, let’s make it about how the system works.”

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What next?

AHHA CEO Alison Verhoeven closed the event, saying the AHHA will be releasing a communique –  possibly modelled on one developed recently with the Public Health Association of Australia (PHAA) on primary health care – to capture the discussions, use it to underpin its advocacy work, and shape its research agenda going forward.

She noted that much of the discussion in the scenarios focused on potential disruptions that might emerge as part of the Federation White Paper process and said that will be firmly on AHHA’s agenda for the next 12 months at least.

And she said she was keen to keep talking to the private health industry, as potential agents of change in the system.

“Obviously for many involved in the public sector, it’s intellectually, emotionally and spiritually challenging to think about the ways private sector might actually disrupt some of the public service, but it’s an opportunity as well as a challenge, I think, like the changing environment around Primary Health Networks,” she said.

“I think for a group like AHHA to be true leaders, we have to look at things in a positive way, how we can make things work by talking with private health insurance for example and choosing the best things out of what they have to offer and advocate that as system change.”

She had also “taken on board” comments regarding the need for skills development in advocacy, discussion about leadership across sectors and professionals, and the potential need for a “national conversation on what want from the health systems”.

In a statement issued after the event, the AHHA said one of the key themes that emerged during the three scenarios was the disconnection across the various parts of the health system.

“Many participants commented that the simulation reinforced the need to tackle issues collaboratively engaging all stakeholders. It was also noted that, at times, those high level talks forget the most important stakeholder in the system—the patient.”

“When a broad change was proposed to the system, it was observed that each party was mainly concerned with how it affected them, rather than the system as a whole. It was also noted that while there is an assumption that policy makers work in the best interest of patients, not much consultation occurred with them….

The AHHA also outlined the top 5 recommendations it pulled out from the day:

• Health policy needs to have clear goals, be evidence-based, well-thought through taking account of all potential consequences, and specific on details for all elements of the system, including providers and patients.

• While financial sustainability of the health system is critical, policy makers must not lose sight of patient interests – these must be central to health policy.

• People working within the health sector need to engage regularly with policy makers at all levels in government to highlight any perverse or unintended consequences of policies, as well as to offer alternative solutions.

• Healthcare cannot operate in isolation from social supports and care, and policy and planning should be undertaken together for this reason.

• Integrated strategies and models could work well for people with high health care needs, however more research is required to better support health promotion and illness prevention strategies, including for generally well people.

• See this short video produced by the AHHA to outline the process and some quick observations. 

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Snapping the participants in action

 • Declaration: Jennifer Doggett and Marie McInerney provided the report above for the Croakey Conference Reporting Service. In a separate arrangement with the AHHA, they also attended the event as rapporteurs on the day, together with Mark Metherell.