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Plenty of room to improve national health and aged care leadership

Introduction by Croakey: The Department of Health and Aged Care should conduct a “thorough and significant review” of its COVID-19 response within the next year, according to an examination of the department’s operations.

“There are important lessons from this experience about what has worked well, what hasn’t worked so well, and what should be done differently to be ready for the next pandemic,” says the Capability Review of the Department of Health and Aged Care.

If the COVID examination is left too long, organisational memory will start to dissipate as people move to different roles and other priorities take over, it says.

(Notably, the department’s reviewers say “there is clearly the question of when the time is right for such a review, as COVID-19 is not totally gone…” – which in itself speaks volumes about the importance of learning some lessons, noting the World Health Organization’s consistent messaging that COVID is an ongoing problem that requires continued vigilance from governments).

The Capability Review makes many other recommendations, including that the department work more closely and collaboratively and in a less ‘transactional’ way with state and territory counterparts, and that other Commonwealth agencies need to develop deeper health policy expertise.

Its recommendations around rethinking health workforce roles were clearly already on the Government’s radar, as per its recent announcement of The Unleashing the Potential of our Health Workforce Review, which was recommended by the Strengthening Medicare Taskforce.

Tweet by Health and Aged Care Minister Mark Butler
Tweet by Health and Aged Care Minister Mark Butler

The review team also heard the department has been somewhat slow to respond to the new Government’s priorities, and that the Health Ministers – as well as wider stakeholders – want the department to provide greater leadership and more forward-looking policy options and strategic advice.

The review also urges the department to improve communication and engagement with the community.

“In the past, mass media campaigns were a key tool for the department to spread health messages,” says the review.

“The experience with COVID-19 has highlighted shortcomings with this approach and pointed to the need for new thinking and new skills in the department. Many of those with complex (and potentially expensive) health and care needs do not receive information through traditional media.

“Indeed, the department needs to reach some people who distrust government and are wary of government messages urging them to participate in programs or use services. Communicating with such communities requires long-term engagement, detailed data and analytics, and a willingness to use influential community members backed by social media to provide information and receive feedback.

“Creating the capability to reach all parts of the Australian community will require a lift in the department’s approach to engagement with communities and their representative organisations, as well a more contemporary approach to communications.”

The reviewers considered the department’s capabilities against five key domains, identified nine priority areas for capability improvement, and based their findings upon desktop research, interviews and workshops.

The review also includes the following details:

• The department’s functions include regulation, funding and financing, program management and administration, direct citizen engagement and policy advice to government, with a policy remit accounting for 10 percent of the economy.

• In 2023–24, the department will administer 20 programs across four outcomes with administered funding of $103.3 billion.

• More than 5,800 people work at the department in eight different worksites around Australia  – at the end of April 2023, 22 percent of the department’s APS staff worked outside Canberra from offices in all capital cities and some regional locations.

• In 2022, the department produced more than 20,000 ministerial products – including 3,403 ministerial briefs and 1,503 ministerial submissions. By comparison, the Department of the Prime Minister and Cabinet reported 2,064 briefs and submissions in its annual report and the Department of Social Services reported 324 briefs with another 1,024 awaiting signature at the time of reporting.

The department’s capability was last reviewed in 2014, as Charles Maskell-Knight well remembers. His article below was first published at Pearls & Irritations.


Charles Maskell-Knight writes:

The Australian Public Service Commission released the second capability review of the Department of Health and Aged Care on 18 August. While the review is not as scathing as the first review in 2014, it still sets out a challenging internal reform agenda for new Secretary Blair Comley.

The 2014 capability review was highly critical of many aspects of the Department of Health’s capacity and performance.

It ranked the department as being a “serious concern” in relation to people motivation (“leadership behaviours cultivate self-censorship and passive compliance, rather than energising employees and ideas”) and outcome-focussed strategy (“the department does not have a high-level strategic policy framework to help it ascertain upcoming demand, model environmental factors and shape policy decisions and work programs into a strategic roadmap”).

The only bright side was a “well placed” rating for evidence-based choices, where the review noted that “overwhelmingly, external stakeholders have highlighted that the department is leading and influencing the international sport agenda through a period of increasing complexity”. Many health sector workers probably wished the department was as successful with the domestic health agenda.

Measured against this very low bar, the 2023 review is much more positive.

There are no red flag ratings, and the department’s capability in relation to a number of aspects of “leadership and culture” and “people” is rated as “embedded” – essentially a credit mark.

Much scope for improvement

However, against all aspects of “collaboration”, “delivery”, and “resourcing and risk” the department is rated as “developing” – a bare pass. There is a lot of scope for improvement.

Every reader of the report will have their own ideas about which areas are most important. In my view – as a health policy wonk – the findings about strategic policy capability are particularly interesting, especially given the damning findings of the 2014 review.

The current review identifies “Integrated strategic policy development capabilities” as the first of nine priority areas for improvement. It observes that:

Nearly everyone this review spoke to expect the department to take a lead in providing a ‘direction of travel’ on major system reform of the health and aged care sectors, and to lead discussions about the detail of that reform…

[D]espite strong policy capabilities in particular areas, there is lack of capability in integrated policy development addressing the interactions between the various parts of the health and aged care systems.”

Following the 2014 review, incoming Secretary Martin Bowles established a Strategic Policy Committee with the aim of supporting integrated policy-making across the department. After Bowles’ departure in 2017, the committee was effectively abolished.

It now appears to have been resurrected in 2022 as the Strategic Policy Forum, intended to “allow leaders to tap into the expertise of their peers to inform policy design and implementation; provide ongoing monitoring and evaluation of critical initiatives; integrate policy development; and iterate the longer-term strategic direction of the portfolio”.

The review notes that the forum “is still in its early days”, and that success will depend on executive support and a sustained commitment to the idea of integrated policy making.

Ministerial matters

However, I believe the review does not give enough weight to the pernicious influence a Minister unwilling to listen to strategic policy advice can have.

It is all very well for the review to argue that “the department should maintain system reform policy capabilities regardless of the needs of the minister of the day”, but when departmental resources are tightly stretched it is understandable a secretary might withdraw resources from a function the Minister doesn’t value.

While I am sure that the broader health sector would like the department to take the lead in major health system reform, the department cannot do this without support from the Minister and the government, as the Commonwealth hospital benefit imbroglio in 2017 demonstrated.

The other finding of the review which struck me was the need for the department to improve its use of data to inform policy. It concluded that “the department needs to empower policy makers at various levels to improve their understanding of the availability, flaws and possibilities of data sources plus an ability to pose answerable questions, and then to use the answers to frame policy proposals and options”.

I was fortunate as a newly-minted assistant secretary in the department to spend time in charge of the branches looking after hospital casemix, MBS, and PBS data, and gained a good understanding of the strengths and weaknesses of these data sources.

Over time it became clear that many of my colleagues had no idea about these data holdings, and there was no formal process to inform them. A lot of time and effort were spent in developing policies in ignorance of the data that may have pointed to a better solution, or indeed data that showed the problem to be solved by the policy did not exist.

The review’s recommendation is long overdue.

The other major weakness in the department’s data capability is the lack of data to inform policy consideration. While the review gives as an example the lack of data-driven metrics to support PHN performance monitoring, there are numerous other more important gaps.

For example, a recent Croakey article by health policy analyst Jennifer Doggett examines the low COVID-19 vaccination rates for aged care residents, and concludes that “there is no single source of data on the vaccine status of residents, which means it is difficult to know whether the Government’s figures are accurate”.

Due to space limitations this article cannot discuss the other priority areas for capability improvement identified by the review, including the need for a systemic consideration of the health and aged care workforce; increasing knowledge about the providers the department funds and regulates; readiness for future healthcare delivery; learning the lessons from COVID-19; developing collaborative and enduring relationships with the states and territories; improving communication and engagement with the community; and building and empowering the mid-level of the department.

These are all important, and they will not come as a surprise to anyone who has observed, dealt with, or worked in the department over the last decade.

New departmental secretary Blair Comley will be busy as he tries to bring the department with him to address the issue identified by the review. Let’s hope he gets the support he needs from Minister Mark Butler and other portfolio ministers.

• Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20.


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