Australian Digital Health Agency: so long, thanks for all the (brightly coloured) fish

Who ya gonna call when digital health is having the most important moment in its history?

When a pandemic has thrown the utility of digital in healthcare into the spotlight, and it’s proven its credentials; when the public is all ears and yearning for more as a result of the introduction of telehealth; when government agencies have thrown the rule book out, taken calculated risks and come up trumps using new digital strategies; when transformation in health has been bowled up, ready for a talented and experienced new digital health agency leader to hit it over the boundary?

An unusually senior career bureaucrat opting to take a few steps down the public service career ladder, whom no one has heard of … apparently.

The agency announced Amanda Cattermole this week as the permanent replacement for Tim Kelsey, a role temporarily filled by the very competent Bettina McMahon. Ms Cattermole is a lawyer with virtually no primary and tertiary healthcare exposure or networking in the sector, no track record engaging the public on complex, political and emotional issues, no formal background in technology, no track record of vision and leadership from the past (that anyone can glean), no real-world commercial experience, no public profile to speak of – and a recent history working in the department that brought us digital transformation in the form of “robodebt”.

As harsh as these initial observations may seem, there is one notable positive. Suddenly the relatively small (and, unless you’re in the sector, insignificant) government agency ADHA, with a staff of about 250 and budget of about $300 million, now has the former COO and interim CEO of the Department of Human Services, which has a staff of 35,000 and a budget of over $5 billion.

This still feels like an unusual pick.

When does the COO of a $5bn venture decide that a great career move would be to take on the head role in a troubled and controversial third-tier government agency with a budget of $300m? If you look at the Department of Health organisation chart, it’s a step down in reporting of about four levels. The CEO of the ADHA doesn’t even actually appear on the DoH organisation chart.

One industry blog has already unkindly suggested that the appointment represents a once high-flying DHS COO being sent to purgatory for the robodebt debacle.

It’s possible.

But whether this is in play or not is not all that relevant, really. Given that such a COO presumably has some serious talent to have gotten so high in such a large, complex and important other department at such a young age, surely this has a chance of being really good for digital health.

What is the Health Minister thinking here?

Is this a highly competent bureaucrat available because of a big departmental bungle, or does she see a career path in sorting out digital health? Or is she a safe and competent pair of hands that can drag the entire digital health thing, and its management, out of the spotlight and back into the depths of government containment where no light can reach?

No more brightly coloured fish flying past our screens featuring big digital transformational projects such as the My Health Record (MHR) or electronic scripts, which catch the public eye easily and are awesome when put on display, but which ultimately don’t make for good eating, and are sometimes poisonous?

No, the next person to run digital health federally is going to be a serious, hardened, oblique technocrat, who will take orders and not stupid risks, and will make sure that there is no more grief for any of her political masters.

None of this is necessarily bad. In fact, given the experience and seniority of Cattermole, the ADHA is now run by someone who knows how to navigate the bureaucracy and politicians much better than anyone before. That could come in very handy.

There are a few other things pointing to this being the new paradigm for digital health and government.

With the exit of interim CEO McMahon, all but one of top seven ADHA executives who started the year in 2019 under Kelsey are now gone. There is no one left of any import from the previous regime. It’s a cleanout that is at first suspicious, and then worrying, in the sense that the loss of talent and corporate memory is massive. McMahon in particular was a quiet achiever whose value in experience and detail would be nearly impossible to replace in the short term. It makes the degree of difficulty for a new CEO with no experience in the sector very high in one way. But in another, it’s exactly what a new CEO and new paradigm need. A clean slate.

It’s going to make for an interesting first management meeting as none of the major positions are filled. Which will make the first board meeting a real test. There is a good spread of influencers and industry sector people on the board. But one wonders who the real chairman of this new setup will be. The ADHA chair or the Minister and the Secretary of Health? Given the chair is someone firmly ensconced in the primary care sector, which some people see as a bit conflicted, maybe we could see the chair as chair and the Minister as the Emperor in the new set up.

Under the circumstances the board is now more important than ever. They are the only ones who can help shape the new paradigm with a new CEO, who though undoubtedly competent in many ways, does not have any sector experience. And while the DHS is surely a complex beast, health, and more so digital health, is complexity in a whole new sector for the new CEO. There are a lot of moving parts to funding, technology, politics, commerce, public advocacy and the like.

Another indicator that this appointment is likely part of a grander plan is that at one point during the search process for the new CEO, apparently, an excited search firm identified some highly experienced and qualified candidates and expressed quite a bit of excitement and enthusiasm to said candidates about their fit for the role. But after pitching their shortlist to the recruitment committee (the Minister?), they came back somewhat downhearted to inform these candidates that while eminently qualified, the “big boss was looking for something a little different this time around”.

Years of experience in the sector, in private and public roles, with failure and success under their belts, in policy roles, consulting roles, senior commercial roles, established networks and with a name in the sector, that while raising some eyebrows (who doesn’t have enemies?) would at least garner some nods on logic and tips of the hat to common sense.

No, we aren’t looking for that type of person this time. We are looking for someone with none of that.

We are going for a paradigm change.

The Department of Health is a little like the forest in Sleeping Beauty. So dense, multi-layered and surrounded by thicket that the very thought of asking an important question on some urgent matter of public health is quickly dismissed as folly by most journalists, given the process, delay and obfuscation that you will almost certainly encounter. You can’t get to the middle. And if you did, you’d worry you might never make it back out.

As far as many of the key stakeholders of the last decade are concerned, Greg Hunt is first and foremost mothballing the My Health Record (MHR). When we say mothballing we don’t mean, switch off and park in the desert or strip for parts; but we do mean, use what we can from the infrastructure developed, so far as it is useful in getting things done in a fast evolving new world of open system architectures, the web and so on. We mainly mean, the MHR will no longer be the central plank of anything digital healthwise from here on in.

This doesn’t seem silly.

What started as a thought bubble from a below-average Labor health minister, Nicola Roxon, many years ago now, got a pretty good run. In fact, it got two runs really as it was dead four years ago but got revived by the charismatic Kelsey for a big last hurrah via “opt-in”.

Hunt’s new CEO pick marks the MHR as a failure, politically. Many would say it’s just a failure, and if you think about what we were all promised, it probably is.

So do we care if it’s being put out to pasture, somewhere at the far end of the top paddock where it won’t be noticed much any more? Where it can live out its remaining days, largely in peace, and still be called on from time to time, when actually useful – which it can be at times?

We might just a little.

Because the new setup looks very much like it also might mothball a lot of public access and input into digital health development.

That would be one very big baby going to the far corner of the top paddock with the bathwater. [This sentence is an outrage – Ed]

What’s so bad about digital health that we need to bury it back deep inside our bureaucracy for the next 10 years in order to get a better outcome?

If key stakeholders – clinicians, medical colleges, technology vendors, patients, public policy advocates and so on – don’t at least have the access they’ve had with the ADHA to the strategy and planning process for some input, how’s that likely to pan out for the entire health system in the long run?

The move by Hunt feels just a little Putinesque.

He has a plan he thinks he can manage by himself and a few close confidants. No doubt part of that plan is to one day become prime minister. But to do that he needs to get his house in order. A second Tim Kelsey might put a big dent in such an aspiration, while he is still health minister. An ADHA in all its public transparency and engagement grandeur, with any new CEO, could dent it. No, best to get more control of this whole situation.

Hunt, by all accounts, and yes, by track record, has been a pretty good Health Minister – everything is relative of course.

So maybe he’s the right man to take everything in house? After all, for more than a decade through NEHTA versions 1 and 2, and then the ADHA and Tim Kelsey, not much went to plan.

How much worse can a bunch of undisturbed well directed bureaucrats, now potentially led by an A-lister from DHS playing reserve grade for a few years, with no outside noise to distract them, do? We’ve seen some pretty spectacular wins on the part of government, both state and federal, during COVID.

For all the bad things you could say about Vladimir Putin, he does get things done.

Given this is pretty much a done deal now, the question becomes, who is on Vladimir’s team here, and who is on the outside? Maybe more importantly, if you’re on the outside, can you make it to the inner circle to help make a difference?

Would for instance, Vladimir, in his wisdom, seek counsel in his endeavours from someone like Grahame Grieve – the founder of international web sharing standard FHIR – who is at once someone who understands everything that is going on in Australia and globally in digital health, and who, after years of hitting his head against many bureaucratic and political brick walls, and making the odd political misjudgment, understands the game perhaps better than anyone. He’s navigated the US political and health tech vendor system and come out a long way in front. That’s saying something. He’d be a good confidant … or at least, sounding board.

Cattermole could do much worse than ask Grieve out for a drink and quick chat before she got started to get a proper lay of the land. Even before that first board meeting.

It’s interesting to think about who you might also want on team Cattermole/Hunt/Murphy, in this new paradigm.

Dr Harry Nespolon would have been great carryover from the previous era. The newly elected RACGP president, Dr Karen Price, has the intellectual verve and drive to make such a team. Emma Hossack, the wiley CEO of the Medical Software Industry Association (MSIA) and ADHA board member, might already be on the inside, by the sounds of things. Maybe Hunt and Cattermole could put together an unofficial digital health COAG?

The good news is that unlike many of the Liberal Party front bench – hello Stuart Robert, Michaela Cash, Michael McCormick, Paul Fletcher and Richard Colbeck – Greg Hunt is not an embarrassing lightweight.

He knows how to stay out of trouble and his management of the COVID-19 crisis has been pretty good, including his eventual decision to drop resistance to telehealth, but also, in his appointment of Dr Brendan Murphy by his side. He’s picked a pretty good formal team of people from whom he can take reasonable counsel.

Hunt also turned down leaving health for Mathias Cormann’s finance portfolio role (which is a sort of poor man’s Treasurer), suggesting that he thinks he can do better with Health and what he knows than move off into a new role.

Hunt staying in Health, Putinesque or not, has got to be good for health and digital health overall given his smarts and ambition.

Hunt (we hope) has a plan, and while it feels a lot less transparent than what we’ve been used to in digital health, and likely more conservative, perhaps after so many years of hype and failure, we shouldn’t be too quick to raise alarm at how he’s setting up to execute it.

So, essentially you can ignore a lot of the first half of this article now.

It’s not like anyone can do much to change what has been set in train.

We are on a new path and should embrace it for what it probably is.

Maybe Hunt, Murphy and Cattermole, can stay the course, develop a process that filters for the right counsel moving forward, and take advantage of the current momentum digital health has as a result of COVID.

As counterintuitive and wrong as it might feel, removing yourself from having to engage in a lot of robust public scrutiny and review can work. It’s why private equity takes public companies private. So they can get rid of the all the noise and distraction and concentrate wholly on their core objectives. You might be able to do this job better behind the deep thicket forest that surrounds the castle at the centre of the DoH, which is ultimately where digital health is likely to be living in the near future.

It’s easy to envisage things a lot worse than where we find ourselves, transparency and public input processes aside.

A change of minister, a change of government, a charismatic new and ultimately powerless non-insider at the head of the ADHA?

Bring it on Greg.

If you can pull your plan (presuming you have a plan something like this) off, we can go visit the MHR in the top paddock in few years, sit back, and reminisce about the bad old days.

Of course, you’ll be PM by then.

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