What is the key to fixing our failing health system? Well, our experiences tell us that there is no single key and no single lock! As such it is better to view health system reform as a combination lock and we need to get all the tumblers about right to unlock the power of positive changes. The difficulty of course is that no one person or group controls all the tumblers, so negotiation and compromise is required.
In my view, many of our past efforts in health system reform have been disappointing because we have refused to acknowledge the interdependencies that exist between such things as how we fund services and how patient services get delivered at point of care. We tend to tinker with organisational structures but ignore the need to engage deeply with clinicians and patients to modernise services on the ground. An organisational restructure in of itself is not a reform!
The reform work starting to happen overseas is showing that a suite of simultaneous and mutually reinforcing changes across multiple design domains is needed to unlock the power of health system change. In parts of Australia, we are also seeing a growing awareness of what it is going to take to modernise our health system and put it on to a sustainable path.
What are the design ‘tumblers’ in our health reform combination lock?
Society– agreeing what we as a society want our health system to do for us, and the things we want our politicians to prioritise
Government– politicians enacting the legislation needed to facilitate the changes required and allocating the budget accordingly
Policy– assembling the research evidence to make sure that our policy frameworks will help us understand what is going to work best to deliver the agreed priority outcomes to patients
Operating business model– ensuring that the funding arrangements incentivise and reward healthcare providers for delivering the services in a way that delivers the priority outcomes
Organisation structure– optimising organisational arrangements to deliver the priority services and agreed patient outcomes
Patient outcome model– doing the logic ‘design’ modelling with patients and clinicians to agree what the actual patient outcomes should be
Service model– ensuring that services are practically organised in a way that make it possible for clinicians to deliver the priority patient outcomes
Model of care– where necessary, re-thinking how clinical care gets delivered, and who provides it
Place of care– tailoring the service models to ensure that they work for people living in different places around the country
People receiving the care– enshrining the culture and practical mechanisms that allow the public to shape their health system into the future
Who needs to be sitting at the health reform ‘design’ table?
Running through the design domains above tells us that we need to involve a host of ‘actors’, including community leaders, politicians, legislators, academics and researchers, policy specialists, clinician thought-leaders, public servants, business managers, service managers, program designers, unions, professional colleges and associations, health service commissioners, health consumer groups, media commentators, and of course actual patients.
Most importantly we need to ground all re-design discussions with the insights of hands-on clinicians and maintain a ‘laser-like’ focus on delivering the actual patient outcomes desired. Most of the criticism of the current system can be attributed to our failure to prioritise patient outcomes, instead preferring entrenched partisan political, institutional, professional, private, and corporate interests.
Health system reform is not easy, it is going to take decades, and it is not for the faint-hearted! A level of political bipartisanship must also be found somehow, and those aspiring to leadership in health should take note.