I recently suggested that it might be useful if the Department of Health and Ageing executive charged with driving health reform implementation, Graeme Head, could start a blog to talk about the challenges involved, and to crowdsource ideas and feedback.
I didn’t realise at the time that the NSW Health Director-General, Professor Deb Picone, had just kicked off her own blog to do exactly this.
Hopefully it’s one small step towards breaking down the barricades that stifle open public discussion of health issues.
While I’m sure Picone is careful about what she says – and no doubt the moderator is even more careful about the comments published – it still makes interesting reading.
Here are some of her reflections from “listening and learning” meetings at various hospitals:
“The issue of equity has been repeatedly raised at our meetings. We all agreed that we need a system that will ensure growth money (recurrent and capital ) to the growth areas of the state. This will become extremely important under casemix funding as the casemix pays for activity but has no provision as tool to ensure the equitable distribution of resources.
…The relationship between the (local hopsital networks) and (primary health care organisations) was raised again. We confirmed it was important to work closely with the Commonwealth to define the difference between primary health care and specialist community health services.
…Blacktown-Mt Druitt raised what is now becoming a common theme from the listening tour that is, certain services need to be managed at a state level. These include; mental health, drug and alcohol, child protection, counter disaster, renal services and multi-cultural health.”
Health reform: a farce
Meanwhile, for those in need of a little light relief from the heavy business of health reform, check out this spoof, titled “A surrealistic mega-analysis of redisorganization theories”. It is by some of the heavy hitters in evidence-based healthcare, and was published in 2005 by the The Royal Society of Medicine.
Just to give you a small taste, here is the abstract:
Background We are sick and tired of being redisorganized.
Objective To systematically review the empirical evidence for organizational theories and repeated reorganizations.
Methods We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people’s realities. We are sorry about this, but it is not our fault.
Results We discovered many reasons for repeated reorganizations, the most common being ‘no good reason’. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.
Conclusions We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.
NHS about to be all shook-up
For those wondering what a Coalition Government might mean for health reform, perhaps we can draw some lessons from the UK.
This Wall Street Journal report gives an overview of the health reforms just announced there, which involve cutting huge swathes of the health bureaucracy and putting more money directly into the hands of doctors, who will decide how the bulk of the National Health Service’s £105 billion annual budget should be spent. It is being billed as “one of the biggest shake-ups in the NHS’s 62-year history”.
Some critical issues for health reform in Australia
The Menzies Centre for Health Policy at the University of Sydney recently held a seminar examining the implications of the health reform agenda (you can listen to the proceedings here).
Thanks to Angela Beaton and Justin McNab (Research Fellows at the Centre) for providing this report:
“Discussion at the seminar focussed on Local Hospital Networks (LHNs), Primary Health Care Organisations (PHCOs) and what they will mean for health service delivery.
Professor Stephen Leeder (Director, Menzies Centre for Health Policy), Mr Terry Clout (Chief Executive, South Eastern Sydney and Illawarra AHS), Dr Nigel Lyons (Hunter New England AHS), Dr Leon Clark (Chief Executive Officer, Sydney Adventist Hospital) and Dr Narelle Shadbolt (Department of General Practice, Hornsby) participated in the panel discussion that was moderated by Dr Barry Catchlove (Fellow of Senate, University of Sydney).
An engaged discussion at the end of the seminar highlighted that while there is a risk that we will be faced with unintended consequences, the current reform process presents us with an important opportunity to create positive change in the health system.
But, as noted by many of the participants, there are several important conversations that must take place if this is to occur – not least of all about the professional leadership that will be required for the development of effective governance to closely link community and hospital-based services.
Health professionals – clinical and administrative – will need to resist defensive tribal reactions to reform. Equally, governments will need to demonstrate clear benefits for patient care or face a wall of cynicism in the face of yet more administrative reorganization.
These were some of the conclusions that were drawn around what needs to happen to make sure these reforms improve health service delivery and outcomes:
• Common governance and policies for LHNs and PHCOs are absolutely required if the proposed structural changes are to improve health service delivery and seamless care across sectors. Detailed and specific information is needed to operationalise the relationship between LHNs and PHCOs, especially relating to budgetary and funding arrangements.
• Boundaries of LHNs and PHCOs are crucial to successful reform and should be closely aligned, where possible reflecting: existing patterns of referral and care, geographical communities, or other social and cultural commonalities.
• The ‘conversation’ of reform has to include not only LHNs and PHCOS but the private sector, NGOs, general practice and allied health, and significant, meaningful representation from consumers. While there was little mention of the important work of NGOs and the involvement of consumers in the National Health and Hospitals Network Agreement, unless all sectors and professional groups are engaged in this conversation, there will be little chance of bridging the gap between what is currently done and how we expect our health system to perform.
• Australian and worldwide health-sector experiences show that organisational change of this scale requires consummate leadership, management and financial skills. The Commonwealth’s requirement that these reforms will not be allowed to result in any net addition to bureaucracy presents a huge challenge, especially in NSW where previous structural change has not bought all of the intended benefits and has resulted in ‘thinner’ administration across wider areas.
Reform, what reform?
DOHA’s chief, Jane Halton, recently told a Senate committee hearing that the responses in health reform consultations had been “incredibly positive”. Perhaps she hasn’t had the chance to chat with rural Victorian GP, Dr David Monash, who recently fired off this angry email to Croakey.
“Reform? What reform?
We in Victoria have been told by state officials that nothing will be changing. Doctors will still not be eligible to be appointed to local hospital (now Hospital Network) boards. The funding will continue to be siphoned into State Government administration as it has always been – a fact confirmed by the abolition of the National Supervisory authority. I have recently read that doctors in NSW’s have also been told there will be no changes in the health system.
They did not change the system to provide single source funding.
What has changed or will change at ground level?
Why is no-one exposing this fraud for what it is?
Simply repeating “health reform” numerous times does not make it so.
Why doesn’t some-one attempt to track where one dollar is distributed to under this new arrangement. A minimum of 10% will disappear into state coffers. The avoidance of this cost to hospital funding is why Mr Brumby so opposed the process initially. We now see why he agreed – the money will not be tracked. Hospitals will not receive more funding than medical CPI catch up entitled them to.
Let’s stop giving this process undue credit as a Reform. Changing where the money is sourced from does not constitute reform of a medical system.
If we are spending monies in the system in the name of a reform that is not happening then why not channel it into areas where it is needed more. Mental Health has been neglected, again.
If there is any truth in the talk of reform it is in the quiet and devious transfer of the control of general practice into the “Medicare Locals” so they it will be placed under the control, by extension, of the State appointed hospital network governance councils, which exclude input by local clinicians by degree. These organisations will be responsible for co-ordinating and organising general practice after hours services and in many cases in doing so will disturb successfully operating existing after hours arrangements.
The plan to voluntarily enrol patients with diabetes is grossly underfunded and poorly thought out but will be proven to be successful. This will occur not because it produces better control in diabetes but because clinics will not allow complex patients to enrol as they will lose substantial fees in doing so. Therefore only patients with well controlled disease will enrol and the enrolled patients will therefore be shown to have demonstrably better disease control than those not enrolled.
We have held multiple reviews of primary health care and then we pick and choose the ones we will adopt according to political whim, much as the Henry Review was also used. On this basis how are we to achieve bilateral support on a primary health policy?”
At this point, it is probably timely to refer you back to the “mega-analysis of redisorganization” whose authors helpfully included an “implications for practice” section, with four key lessons:
- For leaders and consultants who feed on cyclical redisorganizations: Be loyal to organizations always, and to people never
- For victims of redisorganizing leaders and consultants: Remember that the best-laid plans of mice and managers can be disrupted by creative imagination. Exploit the chaos for more worthy goals
- For those in well-functioning enterprises who want to avoid being redisorganized: Fake it. Make it look like you are redisorganizing already: Schedule (but don’t hold) countless meetings; plagiarize, photocopy and distribute (on coloured paper) strategic plans lifted from out-of-town victims; rename traditional sporting and social events ‘team-building’; and get on with doing your job
- For perpetrators of perpetual redisorganizations: Why don’t you just go… reorganize yourselves. ***
Update: A worthwhile read from the former BMJ editor, Dr Richard Smith – based on a presentation to the Royal Australasian College of Physicians. His ten lessons on public health and global health include:
Lesson one: Modern clinical medicine is as out of control as the banks and is unaffordable globally.
Lesson four: You can’t have healthy people without healthy places.
Lesson six: How we die may make a huge difference, and there are positive signs of the compression of morbidity. We must promote the idea that death is normal and a friend.
Lesson ten: the rich can learn from developing countries.
… there are many examples of innovation in poorer countries spreading to developed countries. … Poorer countries have a better chance of building sustainable health systems because they don’t have the inertia and vested interest of the top heavy systems built in developed countries.