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What’s wrong with Health? Lessons from capability review

The Department of Health is a long way from where it needs to be, according to its recent capability review, which found it in dire need of the capacity to produce an overall strategic policy for Australia’s federated health system. That doesn’t come as a surprise to people who understand how the department works.

The process of developing a white paper on reform of the federation, the likelihood of the current fiscally restrained environment continuing and the High Court’s decision on the legitimacy of federally funded school chaplains — which could have implications for hospitals — are all listed as factors that presage a need for a transformation of the department and its role. The reviewers say the federation reform process, which progressed on Friday with the release of an issues paper on roles and responsibilities in health, is “a significant opportunity for the department to exercise strategic influence on future health system thinking and strategy”.

The department has been highly dependable when it comes to delivering on complex reforms and projects it has been tasked with, but the Australian Public Service Commission’s review team says its “strong focus on tactical, transactional and reactive delivery distracts from the development of a proactive, long-term and system-wide strategy”.

Of the 10 capabilities assessed, two are in urgent need of attention: there is almost nothing in place to motivate Health’s overworked and unappreciated staff, and it lacks an overarching “outcome-focused strategy”. UNSW associate professor of medicine and health policy expert Dr Tom Keating, who has considerable experience working with the department, says the review is “a pretty substantial indictment of the organisation”, but also a valuable tool for its leaders.

“I certainly think there is an issue there with overall strategic capacity.”

“I think it’s a very, very useful review, which I hope the department takes on board and responds to,” he told The Mandarin. “I certainly think there is an issue there with overall strategic capacity. They need that, and they also need leadership from government. Government needs to be interested in and be prepared to develop an overall strategic perspective on where they want to take health, and they’re not there now. To be fair, the last government, after their first year, wouldn’t have been anywhere near it either and they put in place processes to get there.”

It was the National Health and Hospitals Reform Commission, in which the Health Department was just one contributor, that ushered in the more “well-integrated overall policy framework”. “For instance,” said Keating, “the primary care policy of the last government was very well articulated, put together on the basis of really substantial consultation with the sector, and was highly supported.” He suggests the Coalition’s current lack of a coherent federal health policy might make the task of reforming the department even trickier.

“I suspect these things are quite deep-seated and they’re endemic to the organisation in a way, but some of it may be related to the current situation as far as government is concerned, because the current government doesn’t have a coherent, overall health policy — it deliberately went to the last election without one — and now its initiatives are piecemeal, unrelated and pretty incoherent,” said Keating. “So in a way, it’s not surprising that the department might be the same, but I think the review, while it’s been done within the last 12 months, probably reflects some deeper things within the department; that it’s not well-geared to develop a coherent, overall policy framework.”

The review found a need to “better connect sources of evidence across the organisation to support the development of a high-level whole-of-health-system view … in an increasingly contested policy environment” and that despite the establishment of a Strategic Policy Unit, “policy discussions are largely constrained within work silos”. The reviewers comment:

“There is broad acknowledgement that the growing prevalence of chronic disease, continued disparity in health outcomes, increasing citizen expectations and unsustainable long-term rate of growth of government health expenditure are some of the many challenges facing the health system. However, notwithstanding the existence of a Corporate Plan 2014–17, the department has not engaged with its authorising environment to help develop a high-level strategy to seek to address these and other systemic issues.”

Until the review, Health was apparently unaware that government and stakeholders expected it to come up with such an overarching strategic policy:

“The department maintains the belief that policy strategy is not sought by stakeholders or the Government. This view is not supported by evidence gathered as part of this review.”

The Department of Health is highlighted. According to the review: "Evidence demonstrates that high demand–low control workplaces face an elevated risk of ill health among employees."
The Department of Health is highlighted. According to the review: “Evidence demonstrates that high demand–low control workplaces face an elevated risk of ill health among employees.”

Delivering services at all costs

On motivation, the review found employees “intrinsically” motivated by their own interest in working at Health, but little else. A very strong track record of delivery has come at a cost. Employees described a “results over people” culture and there is a widespread belief among the various staff and stakeholders interviewed for the review that it can’t go on this way:

“Going forward, many employees and stakeholders commented that the requirement to deliver at all costs on all commitments is increasingly unsustainable in an environment of declining resources. Employees report that they work long hours and under immense pressure to deliver. This is a workplace health and safety risk.”

The immense respect commanded by former secretary Jane Halton came through in the process, but there was criticism of the “command and control” leadership style in the department she led for 12 years. Interviewees variously described senior leaders as “risk averse, outwardly defensive and internally siloed”. Keating says “you can see that reflected from the outside”. The review cautions:

“While this approach may be appropriate in responding to a crisis or national emergency … its application in day-to-day management has resulted in the disempowerment and poor use of its workforce, reinforced vertical silos, limited corporate ownership and potentially hampered innovation.”

The reviewers heard that SES staff work extremely long hours, duplicating each other’s work due to inefficient systems and processes. As a consequence, executive level staff are in no hurry to join them in the upper echelon. As well, the report states that “employees at all levels have overwhelmingly reported that the Executive Leadership Team had zero tolerance for bad news or failure”:

“Employees reported they are fearful of making a mistake or failing to deliver. They report that that this has encouraged a departmental culture of compliance and self-censorship, influencing avoidance behaviours such as the escalation of decisions and a reluctance to report ‘red lights’.”

“My experience of working with the department,” said Keating, “mainly on policy and program review related work, is that it’s populated by a large number of young, highly intelligent, well motivated people, who know next to nothing about health and who move around fairly quickly. Down through the body of the organisation, that’s the sort of profile, and then higher in the organisation you’ve got people who tend to have been there a very long period of time, and so can lose that critical perspective on the organisation.

“So I think that there might be some organisational characteristics that contribute to the failure to identify these things as organisational risk.”

While the capability review process only began in 2011, Keating says the methodology is solid and its results can be relied on.

“When you’re in a department, it’s hard to see the broader view,” he added. “And one of the striking things for me is that — I’ve done a lot of work and a lot of my research around the functioning of complex organisations, and the things which are described here, such as an organisational culture which doesn’t sufficiently value people, a lack of overall strategic view, problems in governance, problems around managing risk; these are the hallmarks of large, complex organisations.

“This is not an unfamiliar thing but it’s so common with large, complex organisations, [that] if you were running one you would expect to have to address these issues. And the interesting thing for me is they seem not to have put in place strategies to address these as risks within their organisational framework.”

More at The Mandarin: Agency report cards: Health, A-G’s, Veterans’ Affairs review

Author Bio

Stephen Easton

Stephen Easton is a journalist at The Mandarin based in Canberra. He's previously reported for Canberra CityNews and worked on industry titles for The Intermedia Group.