You can be a hospital whisperer but you may need to shout!

Do you have some special powers in gaining the attention and cooperation of your local hospital network?   Perhaps you are the one co-opted by colleagues at your PHN as the in-house ‘hospital whisperer’.  In my experience you may need to whisper quite loudly and often to help your hospital counterparts understand the PHN’s role as healthcare commissioners.

The relationships that PHNs have with local hospital networks are varied if not  chequered.  What follows is a “warts and all” analysis!

Why might a hospital network feel indifferent about its local PHN?

• PHNs are not ‘cash cows’ and some in the hospitals think that they should be!
• The relatively small fund-holding makes some dismissive of the PHNs
• Philosophical differences exist between ‘curative acute care’ and ‘ holistic primary care’- there are different worldviews at work
• Historical tensions- mainly hangovers from the days of the Medicare Locals and GP Divisions
• Personal enmities – where  key individuals have had difficult relationships in the past
• Confusion as to what the PHNs are meant to be doing
• Lack of a track record – because PHNs are so new we are yet to establish our credibility
• Rejection of the PHN’s role as “system integrators”
• Rejection of the PHN’s role as reformers- after all, what’s wrong with the current system -we just need more money for our hospitals!
• Rejection of the PHNs as unwelcome agents of the Commonwealth playing in State or Territory business
• Local politics where key individuals are affiliated with different political parties
• Philosophical positions-  some feel that primary care is under-performing and cannot be remediated!

No doubt you could add to this list.

Regardless of the extent of the challenge it behoves us to understand the local impediments to an effective relationship and strategise to overcome them.  PHNs simply won’t meet their potential until they can secure an effective and productive working partnership with their acute care colleagues. There is a lot hanging on this for all concerned. 

When talking about the hospital networks we might be tempted to think of them as essentially homogenous, but this is not the case.  Those who have worked in hospitals know that each is unique having its own micro-cultures, cliques,  interest blocs and power dynamics.  Hospitals are indeed complex ‘beasts’ in need of some ‘whispering’!

To complicate things even further Hospital Networks can be incorporated differently in each of the jurisdictions with variation in accountability and levels of  local autonomy.  Some hospitals in fact have a combative relationship with their State health departments and are unashamedly parochial in pursuing their interests.  It’s definitely not a big happy family and when working in the hospitals I didn’t get a lot of Christmas Cards!

What drives the behaviours of people in leadership roles in hospitals?

There is no simple answer but I proffer a few observations that might be useful.

• Hospitals have become increasingly KPI- driven as governments have ratcheted up performance expectations over the decades.  If the PHN’s activities do not speak directly to the hospitals KPIs it is hard for hospital administrators to justify any involvement in the work of the PHN, let alone co-commissioning.
• Many of the KPIs are about improving patient access and throughput e.g NEAT targets, elective surgery waiting times, etc.  This stands somewhat at odds with the objectives of the PHNs which are more about reducing hospital demand through strengthening the local primary care system.  However,  KPIs like unplanned hospital readmissions is where interests may overlap.
• Hospital executives have a very difficult time retaining the support of senior clinicians and maintaining cohesion across the various competing medical disciplines.  The PHN’s direct engagement with senior clinicians is often viewed as disruptive and unwelcome.  This can be the source of serious conflict and in my view needs to be addressed at a Board to Board level to establish the ‘rules of engagement’.

Why should a hospital network make friends with its local PHN?

The capping of the Commonwealth’s contribution to public hospital growth funding  from July 2018 will eventually drive a new paradigm. This will gradually see hospitals move away from increasing patient access to one that sees more of a focus on better patient demand management. Sensibly Hospital executive teams are starting to look to partner with their PHNs so that they can manage their constrained budgets into the future- their job security depends on it.

Beyond the financial considerations there is a growing awareness from hospital clinicians that the current systems and models of care will not be optimal for an ageing population living longer under the burden of complex chronic illness.  I am personally heartened to see so many hospital consultants reaching out to the PHNs for assistance in driving  internal change in the acute care and primary care interfaces.

What makes for a cordial and collaborative relationship between a PHN and its hospital networks?

While every region is different I would suggest that the following are foundational to an effective partnership:

• Alignment of KPIs – and this is something for the Commonwealth to pursue with their State counterparts
• A commitment to work toward joint regional needs assessment and planning
• Cross-Board appointments
• Formal and regular engagement including occasional joint Board meetings!
• Conflict resolution protocols
• Joint commissioning of  innovation  the parties learn how to work together by working together!
• Resolving historical and personal differences  – so ‘bury the hatchets guys’ its not all about you!
• Desist from playing party politics – it will end in tears otherwise!

Thought Starters:

1. How do you rate your PHN’s relationship with its hospital network(s)?
2. Shouldn’t everyone in a leadership role in a PHN be able to do some “hospital whispering”? Perhaps some training is in order.
3. Do the hospital networks need “PHN whisperers”?   A conversation takes two people after all.
4. How well do we understand the different ‘languages’ being used?
5. How might we resolve the tensions that exist between a medical model of health prevalent in hospitals and a social model applied in primary care?

Keep an eye out for the next article that talks about the role that PHNs can take in decompressing Hospital ED waiting rooms-  quite timely given the peak Flu season is upon us!

Please leave a comment to keep the conversation going!