Martin Bowles: understanding health as a system


December 1, 2015

Being out of the system for quite a while, coming back was really quite an interesting time, because what I saw was not really a health system. I saw healthcare, and I saw we do it pretty well generally, but what I saw was quite a deal of fragmentation and disconnection across what we like to call the healthcare system. And that fragmentation and disconnect was around the primary, secondary, aged care interfaces, it was across private and public, it was across the different types of care that we might receive, and it was definitely across the states, territories and Commonwealth.

I think in fact what I was actually seeing is many healthcare systems. Not understanding that there were interdependencies across all of the different parts of what we need to understand as our system. Sitting as the head of the federal department I thought we needed to work really hard with stakeholders to try and actually make a difference. To try and actually lift this up to a more strategic conversation. And I did focus particularly on the states and territories because they are quite integral to getting the outcomes that we need for the healthcare system.

What I was trying to do is to create an opportunity for a strategic conversation. So the first few things I did was to organise sessions with the states and territories outside the normal Health Ministers’ Advisory Council process, a very formal mechanism where we actually get things done across the country. But by creating an environment where we could have a conversation around what we saw as the healthcare system did actually give us, I think, quite a number of opportunities.

“I’ve never seen so much self-interest, this is a great opportunity … and all we’re doing is talking from our own perspective.”

Another imperative was getting the stakeholders together. I pulled the top 28 stakeholders into a conversation where everyone had their own interests, everyone talking about the health system from their perspective, from where they sit.

While I was trying to work out how to actually say to people this is the problem we have because everyone is coming from a slightly different perspective on the same thing a very wise participant just said it all; “I’ve never seen so much self-interest, this is a great opportunity, the first time and I’ve been doing this for 30 years, we’ve actually been in the room together, and all we’re doing is talking from our own perspective. We have to actually start to have a different conversation” and I thought there it is. And that was how we’ve actually really started to drive some of the big changes that I think we need to do.

It’s bigger than that though. In my Department of Health we needed to have a look at ourselves, how we actually get strategic policy at the centre of our thinking, and one of the first things I did was to put data, analytics, evaluation and research right at the centre of our strategic policy and innovation. We didn’t really think that way, and for me to deal with this issue we do need to be quite strategic in our thinking.

From hoarding to sharing

We have some of the best data in the world. One of the problems I saw was everyone owned a little bit. Someone owned PBS, someone owned MBS, but then we have registries, then we have health private data, then we have the public hospital data. We’ve got bits and pieces of it all over the system. Nobody wanted to share.

We have some of the best data in the world. Nobody has a PBS or an MBS like we do. We use it as a payment system; we don’t use it that well, but it can be absolutely invaluable as a policy tool.

I was told we cannot share PBS and MBS data with the states and territories and yet I know how valuable this data was for their health authorities  so they could actually link data and come up with new ways of dealing with patient flows and other health planning.

So I challenged why we could not provide this information and now we are which I know is appreciated by jurisdictions and now we are starting to share much more information while still protecting people’s privacy.

Incentives when chronic disease is commonplace

There’s also a number of structural issues in our health system that undermines the system’s efficiency and effectiveness and we have the government overlap, the states, territories, Commonwealth issue. We have the MBS which is a fee-for-service based model therefore very transactional in nature and open to perverse incentives.

We have chronic disease which is increasing at rapid rates where about half our population have some form of chronic disease particularly including things like mental health these days. 20% of our population have two or more so how are we starting to deal with things?

I think there is also a real debate around the appropriateness of care. Are we doing the right thing to patients? I think sometimes our systems allow us to do things that at best don’t help healthcare of our patients. Sometimes they might actually do more damage and that’s not a good thing for a healthcare system.

“I don’t think this is beyond us to resolve, we just have to have that combined goodwill and courage…”

It is for this reason that the Australian government has commenced a number of reviews including the Primary Health Care Advisory Group which is looking at integrated care, particularly around chronic disease; looking at models of care, and looking at funding models, because it is really important.

There is also the MBS review that is looking at the 5700 items on the MBS, most of which have never been reviewed for appropriateness and we also have reviews into mental health, private health insurance and other areas of health that could benefit from structural reform.

I think the work we are doing today is about trying to achieve a health system that is sustainable, that will survive the test of time. One that will build on the strengths that we already have there.

I think we will always have interfaces across the component parts of our system, we just need to manage them. I don’t think this is beyond us to resolve, we just have to have that combined goodwill and courage to actually take the decisions that we need to take. And to look for innovative ways of doing things into the future so we don’t leave a lesser system behind.

Overall I don’t want us to waste our opportunities. This is I think is a unique opportunity we have so let’s not waste it.

This is an edited extract from a speech Martin Bowles gave to the New Horizons conference at UTS in Sydney on November 23.

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