10 November 2022

Bursting the ‘it’s too big, complex and hard’ health reform bubble

Government Money

Ten practical and doable steps to health reform in a system where it’s very hard to know where and how to even start. 

Everyone talks of an urgent need for significant health policy and funding reform in Australia but when you get down to the nitty gritty of how do you do it, the barriers to meaningfully even starting are huge.  

By huge, read mostly very complex and difficult politically.  

Not only would you need a very brave and emboldened new government in Canberra (hang on a minute, did we just get that?) but you’d need one that didn’t have quite a few other more robustly burning platforms to deal with before health (aged care, NDIS, inflation, wage growth, energy policy to name just a few) but one that was unusually visionary and had a bit of money to spare. 

Big obstacles to meaningfully getting started include: 

  • Arguments made by the “it ain’t broke so let’s not try to fix it just yet” crew, who defer to a system that manages acute care better than most other systems in the world and is generally delivering better outcomes overall than most as well. This approach seems pragmatic but it entirely ignores the very obvious evidence base that says the system needs to shift quickly to managing chronic care via an outcomes focus. 
  • The state versus federal health management and funding set up, which was OK for acute care management when hospitals needed to be your key asset but is not OK when you need to shift the focus to integrated community based care. The unmovable obstacle to reform here is breaking down our federated model of funding and the downstream signals that is sending to management. 
  • A public service (especially in Canberra) that has been gutted of management power and ability to thought lead, as, over the last decade, it’s been bullied into being an instrument of getting a party re-elected rather than of actual public service. 

When I go to health reform type events (even our own, Wild Health, which ran in Melbourne recently) by the end I’m always left a little debilitated by the feeling that we all wasted our time discussing what we should do, or could do, when in fact no one is empowered really to do anything meaningful.  

Encouragingly, at the recent Melbourne Wild Health, we had quite a few policy people from government listening in. So it’s not like some of the key public servants don’t care or have given up. Many do see the slow-boiling frog issues at hand in our healthcare system and are thinking about how we can overcome the not insignificant obstacles listed above. 

Someone at Wild Health said the words “coalition of willing”, which was a really interesting concept for how we might get to the starting line. Get enough influential people with the right ideas banging on enough of the right doors to get a start on things. 

One of our Wild Health moderators, Jay Rebbeck, has taken a very pragmatic approach to all these problems.  

He’s a consultant, so bear with this (yep, that’s cynicism you detect about consultants), but he’s broken down the key issues in a short and easy to read white paper (some of which came out of the Wild Health Melbourne panel discussions) as a sort of straw man starting point for everyone thinking about the problem. 

That white paper is here and below if you’re that intrigued you want to break off straight away and read it, but for those who need a little more prompting, following is a synopsis of the paper.  It’s 10 steps – yep, 10, like in AA, which may or may not be a relevant metaphor given how hard it is for us all to kick our old healthcare model of care habit – and some logic for why you might want to read the whole thing. 

The best thing about Rebbeck’s 10 steps is that he’s developed them with all those big obstacles to getting started front of mind.  

The foundation of his thinking on getting started is that you can’t do this too quickly, for very obvious reasons. 

The key one is that nearly every player in the system you are talking about revolutionising has a vested interested in the existing (old) system not really changing. For most, it’s their livelihood, so even the forward thinkers are going to have to worry about how too much change might affect their ability to feed their families.  

A break-the-glass transformational approach won’t work here, argues Rebbeck. 

Which might make you ask why NSW Premier Dominic Perrottet said on the ABC a couple weeks back that our healthcare system is broken and is urgently in need of transformational change. It’s a politician thing probably. Sounds great but it’s meaningless. 

You need a framework (and Rebbeck’s sort of providing us with one) that sets objectives with an at least 10-year time frame (enough to not threaten anyone who is in the system today but give them reason to move on stuff still), and meaningful steps that you can take within that framework to start making your way to real change. 


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Rebbeck’s 10 step plan.

He’s not actually saying it in the paper, but he’s surely implying that the federal government doesn’t actually have an overall plan yet, and without that it doesn’t have anything to be able to frame even short-term objectives for change.  

It’s a super basic and simple concept. Make a plan with long-term objectives from which you can work backwards, and develop short-term objectives that are leading to something much bigger you want to change in the future (as much as I love to hate consultants, often they’re very good at working out how to eat elephants in rooms). 

A plan, by the way, is not the “Primary Health Care 10 Year Plan”, or new legislation for aged care reforms, or a better plan to make sure the NDIS doesn’t send us all broke.  

It’s something that takes in all aspects of healthcare including these sub plans. It’s something that is a lot more holistic around the long-term health of our population, and, if you talk to Rebbeck, it probably should be going as wide as encompassing as many of the the social determinants of health in the country as possible (so non-medical factors that significantly impact on health such as unemployment).  

It would also likely include addressing some very practical things that are currently pretty messed up, like how we approach interoperability in our healthcare system (at the moment we talk a lot and say we’re doing a lot, but any benchmark to most overseas countries with their act together on technology and interoperability, including the US, which should be embarrassing to us, leaves Australia severely wanting). 

Of course, Rebbeck is a consultant at heart, so if you’re going to do a decent plan with objectives you’re going to need to do a bit of pre-work to better understand the nature of the problems you’re trying to solve, even if you think you know them inside out already. 

He doesn’t mention this in his paper in terms of the overall plan for government, but he does in respect to his idea of vertically integrated regional health management units, saying they’d each need their own strategic assessment prior to getting going.  

Meaningful strategic assessment is part of what Rebbeck teaches a lot of PHNs about commissioning: if you want to commission services efficiently you need to reasonably understand what you are commissioning services for before you start. 

The best aspect of Rebbeck’s 10 steps by far is that they are mostly all doable within the existing significant constraints of our system, including the federal state divide in management and funding of healthcare. 

His strawman premise is that getting started isn’t actually that hard (in fact some states like NSW have sort of already started with things like co-commissioning trials between LHNs and PHNs). 

His core theme is that you need to (and can) move to regional vertically integrated management of health, whereby in some way you cojoin PHNs and LHDs or their equivalent (HHS in Queensland), both of which Rebbeck points out are, mostly, conveniently overlapping geographically.  

Critics of this tactic will say that you can never make states work with the federal government well enough to make this ever succeed because of the funding divide and the signals it is sending, but Rebbeck is proposing eating that elephant one bite at a time with the full intention of eventually eating it all.  

He is advocating the obvious solution that everyone loves to talk about, but with it a manageable path to get you there. 

As a part of the solution, his 10 steps include collaborative co-commissioning (where LHDs and PHNs commission with joint objectives of the same region in mind), collaborative system leadership, joint strategic needs assessment, joint regional health and wellbeing strategies, joint population analytics and regional performance management. 

They are all bites of the federal/state paradigm elephant and you’ll note that “collaboration” features a lot, which might be a weakness in the end. 

If you can work out the collaboration bit properly it will get around the idea of breaking down our federated model of governments, which isn’t going to happen (or it won’t in time for healthcare reform at least). 

Developing a meaningful integrated regional healthcare structure will be able to shift systems focus a lot more into the community, yet keep the hospitals appropriately connected and integrated as you go. 

Almost amusingly, Rebbeck’s tenth step is labelled “progressive funding models”.  

This is consultant speak for state and federal government’s collaborating enough as they go to acknowledge the changes and develop its funding set up to meet those changes as it goes. It’s a bit of a big leap, but it’s not like state and federal governments don’t have huge gains to make if they participated in the experiment.  

In systems oversees where there is true vertical integration of funding and care regionally (including some HMOs in the US), the number of hospital beds and hospitals are actually declining now.  

The cynics might say this is never actually going to happen because the states and the federal government will never agree to work together in that way out of self-interest. 

But if you get anywhere near where some overseas regionally managed systems of care are getting, you are going to take a lot of increasingly low return cost out of the system. It’s something that both the states and the federal government desperately want and need. 

No matter which way you look at it, both have a stake in making something like this work over time. 

All Rebbeck is doing in his strawman white paper really is offering a way to cut up the seemingly insurmountable problems we have in kickstarting meaningful reform via practical, unthreatening, and sensible (even attractive) steps that add up in the long term. 

It’s a very interesting and easy read. Again it’s HERE

If you find any of it even slightly compelling you are going to be interested in our next Wild Health summit, which is going to be held in Canberra next year (on May 4 at the Portrait Gallery, so maybe pencil the date in) for hopefully obvious reasons. 

Essentially, we are going to start where our Wild Health Melbourne reform summit left off (a lot of interesting ideas to move on reform with people who are interested (the willing) and using a lot of the thinking in Rebbeck’s paper below, attempt to broach the many important questions around whether you can actually do any of these things). 

Rebbeck is going to be there to help, with a lot of other influential and committed thinkers. 

Maybe we can get somewhere after all. 

If you would like to register you interest to hear more about the upcoming summit, please email Michelle O’Brien at michelle@integratedhealthcare.com.au.

Wild Health Melbourne 2022 post event content is available for purchase here – $195 (inc gst).