14 September 2022
Me lord (Mark), I have a cunning (healthcare) plan
You can’t achieve meaningful healthcare reform by ticking the pre-existing boxes that a whole lot of lobby groups hand to you when you start governing. Everything is connected.
Healthcare in Australia has a policy climate change problem.
Our system is no longer fit for purpose and hopelessly ill-equipped to manage the near future (see chronic care crisis), but because in relative terms the system feels better than most others around the world, we lack the impetus that a burning platform, like what has happened to healthcare in the US (it’s a bad mess), brings to the issue.
Nearly everyone can see and articulate our problem, but for various reasons hardly anyone individually can do anything about it.
It’s a problem of the scale of climate change in terms of quality of living to the public and costs to the country.
So far though, we are all slowly boiling frogs.
Interestingly, covid triggered a lot of interest in tackling the problem far harder.
In a manner, it was healthcare’s 2019 bushfires.
But that shock is already receding and with it the will of those within the system to innovate and seek systemic reform.
We are apparently content to wait and see if we end up seeing healthcare’s equivalent of the Lismore floods and cyclone Yasi in suddenly increasing frequency, without any proper preparation.
Again, we all see it, but in each of our siloed, and probably super-stressed parts of the system we operate and are struggling just to keep our heads above water, there is very little we can do to start addressing the BIG problem we ALL have.
Underlying everything, we have a whole lot of people consciously and unconsciously vested in (it’s mostly the latter) no or slow change.
Most everyone in healthcare is ultimately paid by government for what they do now.
Who wants to risk losing their job in the short term or having to change jobs by changing that job too quickly?
It’s the climate change, change paradigm. We are mired.
Notwithstanding, with a new government we have the flurry of new activity you’d expect from an optimistic, energetic new perspective out of Canberra.
The thing is, so far this dynamic has amounted to a whole lot of competing and usually siloed lobby groups, asking for things that might make sense when addressed individually within their silo, but don’t usually make much or any sense when you consider the whole system and its future.
We’ve never had a bipartisan framework at the federal level for approaching reform, so no parts of the system are able to co-ordinate well in reform, even if they wanted to.
In addition, without any plan or framework to rely on for managing investment risk, the private sector is not able to move on with helping us innovate our way to the future using a myriad of new technologies now available to us, especially the cloud-based ones, that could help.
New government or not, we appear to be in real trouble here.
I suspect some of us think (some hope) that a new government dabbling in what are essentially compartmentalised problems of different interest groups – groups like general practice, which has managed to strongarm the government enough to at least try the Strengthening Medicare Taskforce – will somehow end up making everything turn out OK.
It’s a connected ecosystem where if you push down on one part, things pop awkwardly outwards somewhere else, often with dire consequences.
It’s ironic to describe it as a connected ecosystem because there is so much disconnectedness as part of the problem of the system today – hospitals not talking to primary care is the big example.
You have to look at the whole to work this problem out, and at the moment no one is doing that.
No one is even talking about doing it.
Our healthcare system is a monster of a complex set up, with historical baggage in every corner lying in wait to blow up any meaningful attempt at change.
Someone (Mark … it’s you and your friends) needs to get in a helicopter, get above all the moving siloed parts, look down to see how these parts are interacting (or not) now and start trying to figure out how they might better be architected and positioned against each other for a more functional future for the “whole system”.
If the government undertook this relatively simple (in theory) consulting exercise, they should be able to develop a reasonably sensible mid to long-term set of objectives for the whole system and a broad plan (and regulatory framework) to achieve meaningful change over time.
Everyone might not agree on all of it at the start, but at least everyone in the system would have a common government generated framework and set of rules to work off moving forward.
Adjustments for mistakes in any initial plan can be made along the way.
The important thing is to have a plan.
If you think that this approach sounds a little like the recent jobs summit, you wouldn’t be far of the mark.
We probably need a healthcare reform summit, in the mould of the jobs summit as a starting point.
To be clear, that is not the Strengthening Medicare Taskforce.
If you were doing a back-of-envelope early ideation exercise (if you work with consultants this is the bit where they get most of the people who know what is possible in a room with rolls of brown paper and lots of brightly coloured post-it note pads to write on), what’s the sort of obvious stuff that might start emerging given our current key system healthcare components, settings and interactions?
Here’s a couple ideas that might get on the odd post-it note on the roll of brown paper, none of them mine.
First, what are we trying to achieve here?
What’s our purpose or goal?
At its crudest, that Joe and Betty barbecue (actually that’s a very white person’s demographic persona set, so it will need to be far broader than that) have improved health outcomes over time. That we have a system that creates for them a better life through better health, which is also affordable, ideally at least, as affordable moving forward, as it has been in the past, per head of population. And that we improve health equity substantively as we go – read, improve the lot of CALD-type populations, which tend to fall into the cracks.
So, better health outcomes for all individuals at the same or even less cost moving forward.
There’s big hairy ass goal to put down at the start, another consulting term and technique – BHAG.
OK, what are the key component pieces we could play with to try to get that to that BHAG in Australia?
Here’s a few:
- LHDs, HHSs or whatever you want to call them: regional hospital management set-ups. Today they are the monsters of system in terms of funding and ultimate influence, and you can easily suspect that given where acute and chronic care are heading, their current role and funding base risks being out of whack a fair bit moving forward. We probably need less giant hospitals moving forward no matter how politically attractive they are.
- PHNs – improved primary care management is a big secret to tackling chronic care much better. PHNs are a great idea – regional primary care management from a community population perspective, but currently its a lottery of great to badly run organisations which aren’t performance managed or governed properly. They should probably be given a lot more influence in the system over time given their strong community perspective, but a lack of cohesion in governance and strategy from the top, and too little overall funding and influence against their LHD cousins is retarding realisation of their potential.
- GP networks and services – see above for future secrets to better chronic care and overall system management. GPs are under siege and stuck in the past family practice small business community care paradigm. They are being carved up by smart financial start-up plays in telehealth harvesting low hanging consulting fruit, by a government that says they get it, but won’t pay them better, and by hospitals who have worked out they need to follow their patients out into the community and manage them to achieve greater efficiency, but can’t easily work with GPs because of the funding set up and technology. Even private health insurers are starting to eat the lunch of GP networks by offering various infill services. The GP colleges should be helping but they seem to be stuck in their old worlds trying to resist change rather than help their members navigate inevitable changes. GPs are even. being put upon, ironically, by some PHNs, who regard GP networks as the very inefficient in terms of community health management. But GPs are the secret to the future of the system (read on) so someone needs to pay attention and help, but in a much better manner than is likely to be achieved by the Medicare Taskforce because GP changes need to be carefully co-ordinated with other major system changes.
- Allied health networks – technology will make working between GPs, Allied, Aged and Hospital care feasible.
- Private Health Insurance companies – some might not think they have a place, but they’re not going away, and the efficiency of private sector models can help system efficiency if regulated correctly and it already is in some parts of the system.
- Private hospital networks – see above.
- Medical software vendors – much better data sharing is a key to being able to run a system based on outcomes as opposed to activity, but all our software vendors are stuck developing and maintaining very old technology platforms for reasons of market size and economics. They need help to transform. And they may need a bit of stick to go with the carrots.
- Aged care facilities and services – aged care is indisputably a healthcare system issue, yet we want to fix it largely in isolation from all of the above for some reason. During covid, smart hospitals demonstrated that being connected to and helping manage aged care was vital for the efficiency and goals of the overall system.
These components inform partly who you would get into the same room to start workshopping this problem from a whole system standpoint.
You will note that we are going far wider than just an aged care commission or a strengthening Medicare taskforce.
Now let’s think of a few really dumb things we still do for reasons which once might have made sense but no longer do.
We can put those things on standout bright pink post-it notes for effect.
Dumbest thing to start?
Our system remains steadfastly split between hospitals and community-based care based on a funding paradigm that splits the responsibilities between the federal and state governments and which makes proper longitudinal patient management largely unworkable.
Everyone knows if we could migrate this setup over time (it’s a giant change so you have to have a long and well developed roadmap that doesn’t leave anyone off the bus in the journey to get there if possible) to one where regions with common population health issues operated in some way under one management group with common governance we would likely set ourselves on a path for massive transformational opportunity for patients and the system.
This regional health management structural set up is the most common in other countries around the world already for good reason. We can even see it, perhaps ironically and certainly controversially, in closed loop privately controlled systems like the HMO Kaiser Permanente in the US
While we probably want to steer well clear of more privatisation no matter what – profit and health generally never end up working out too well – we should still look at that HMO and think, “wow, that’s what you can achieve for patients and systems efficiency if you integrate all component parts of a health system”.
So, there’s an objective for the future with clear purpose.
Certainly not for next year, we don’t want to don’t panic anyone.
But a goal that one day makes a lot of sense.
You can probably see where this all might be going.
With that one objective which you could put sufficiently in the future to not overly threaten all the interested parties in the room today, you can start working backwards to see how you might get to it, without too much collateral damage to the workers in the system or the system itself.
Such a goal feels like it was never on the table a year ago. The states and the feds would have torn each other to shreds in the room you put them in to discuss it a year ago – see what happened in blame gaming during covid lockdowns.
We might just be in a new era of co-operation where the new government and the states could get in a room and start workshopping the possibility.
If we are in that sweet spot, it’s maybe not going to last long, so we need to get on with it.
It doesn’t need to be revolution.
“OK, who put this bright yellow note on the wall with this idea. It’s interesting whoever you are?” (not my idea readers, if you think it’s dumb or unworkable).
Could we take an already half-functional health region with an already co-operating (and co-commissioning) LHD and PHN and pilot merging the two organisations formally for management and governance purposes, to see what might happen? We might even try more than one region if we can find two that work that well together already.
It would just be interesting to see how many PHNs and LHDs put their hands up for a go at something like this if it were put on the table.
Once you did something like this, you’d have all sorts of interesting downstream things that would need to be better co-ordinated to make it work.
One would be how you now funded this region between the state and federal governments.
Even how you funded GPs in that region perhaps.
Would new funding signals, and better co-ordinated management end up triggering a situation where you transformed the technology base of the primary care and aged care communities, so that hospitals, GPs, aged care and even allied care could actually share their data far more seamlessly and securely?
This might be just one of many coloured post-it notes on the wall of a room of smart and newly motivated professionals being moderated in a manner that is collegiate, not adversarial. No idea is a bad idea (which I totally love as another commonly used consultant moderation tactic, but is obviously wrong).
Imagine lots of colour and notes, and brown paper with columns you start stacking and ranking the notes, and, cue drum roll, formulating a broad long-term framework and plan for the whole system and everyone in it.
Who wouldn’t want to go to this Healthcare Reform Summit and contribute in some way?
Wild Health’s upcoming Melbourne summit on October 18 is not the above described summit (unfortunately), but, it’s going to try to touch on a lot of the issues raised in this article. If you’re interested, you can see the full agenda and speaker list HERE and register to attend HERE. Note: we are starting to run out of seats.