Changing the dynamics of the health care in Australia: A path for improving the quality of health careAngus Corbett, Honorary Associate Professor, Australian Institute of Health Innovation, Macquarie University; Adjunct Professor of Law, University of Pennsylvania Law School, Philadelphia

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The problem: systems at scales

7/6/2018de Savigny D and Adam T. (2009) Systems Thinking for Health Systems Strengthening. In: Alliance for Health Policy and Systems Research and World Health Organization (eds). Geneva, Switzerland: World Health Organization, at p.322

National health system

?

Safety

Finding strategies for changing the dynamics of thenational system of health care to improve the qualityof health care and to improve population health?

Safety: Health care professionals at the “centre” of systems

Immanent Organisation

Safety II: Tractableor

Responsive ?

Health care professionals

Information, finance,

leadership delivery & workforce

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Improving the quality of health care is a strategy for improving population health.

Health system as patterns of interactions between building blocks

“System-level interventions” designed to affect interactions between building blocks rather than address the problem directly

Interventions directed at health care organisation and management are “system-level interventions” designed to improve quality of health care

7/6/2018de Savigny D and Adam T. (2009) Systems Thinking for Health Systems Strengthening. In: Alliance for Health Policy and SystemsResearch and World Health Organization (eds). Geneva, Switzerland: World Health Organization,.4

Using health care organisations to improve the quality of health care

1. To Err is Human – health care organisations as “leverage points” in systems.

2. A characteristic of U.S. health system – not Australia.

3. Polycentric system, multi-payer, multi-provider, multiple networks – the health care organization is a potential leverage point, e.g., ACO’s, Medical Homes, & bundled payments

4. “The American patchwork quilt of services, providers, insurers and regulation which masquerades as a health-care system should never be seen as a model for adoption.”

7/6/2018Mossialos E, Djordjevic A, Osborn R, et al. (2017) International Profiles of Health Care Systems. New York, NY: The Commonwealth Fund.Jeffrey Braithwaite, Health‐Care Reform Under President Clinton: Issues, Ideas and Implications, 54 AUSTRALIAN JOURNAL OF PUBLIC ADMINISTRATION (1995).

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Attuning the Australian health care system to improve population health

• Responsive to population needs

• Responsive to workforce and delivery

7/6/2018Mossialos E, Djordjevic A, Osborn R, et al. (2017) International Profiles of Health Care Systems. New York, NY: The Commonwealth Fund

Elizabeth Bradley and Lauren Taylor, (2013) The American Health Care Paradox: Why Spending More is Getting Us Less, New York (Perseus Books Group: NY, 2017),

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Population

Population healthGOVERNNMENT AT A DISTANCE, GOVERNMENTALITY AND FOUCAULT, OR “NEW” PUBLIC MANAGEMENT

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Looking backwards –planning v. individualism

The ensemble of institutions, procedures, analyses and reflections, the calculations and tactics that allow the exercise of this very specific albeit complex form of power, that has as its target population, as its principal form of knowledge political economy, and as its essential means apparatuses of security.

“The tendency … which may be termed government, resulting, on the one hand, in the formation of a whole series of specific governmental apparatuses, and, on the other, in the development of a whole complex of savoirs.”

The process by which the state “gradually become ‘governmentalized’” (p.103)

On the 18th of October 1976 Friedrich von Hayek met with Malcolm Fraser in Parliament House. The following is an account of part of their exchange:

“Hayek … turned to the issue of social justice: it was, he stated, a misleading and unsatisfactory term which encouraged the growth of government welfare spending. Fraser responded sharply: ‘What do you do when aboriginal children are dying?’ Hayek suggested that the government should consider a minimum income system, to avoid the obvious problems of the current system which simply encouraged special interest pressures for more spending.”

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Michel Foucault, Governmentality, in The Foucault Effect: Studies In Governmentality (Graham Burchell, et al. eds., 1978).

Rafe Champion, Hayek in Australia, 1976, in Hayek: A Collaborative Biography, Part VI Good Dictators, Sovereign Producers and Hayek’s ‘Ruthless Consistency’ (Robert Leeson ed. 2015), 242.

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Looking forward – “governmentality” and governance of populations

“Governmentality” – national planning or “freedom of choice” for entrepreneurial, state-sponsored doctors

National Health System

Entrepreneurial, philanthropic,

and state-sponsored

profession: The centrality of

choice and the “emergence” of

a system of health care

7/6/2018Cass M. (1964) A national health scheme for labour, Melbourne, Vic: Victorian Fabian Society.

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A national health scheme for Australia

TitleVictorian Fabian Society pamphletPublisherMelbourne : The SocietyDate1953Formatv. ; 21 cm.

“Governmentality” – systems thinking - influencing systems

1984 – Medicare becomes operational

1987 - Australian Institute of Health and Welfare established

1991 – John Braithwaite – “Responsive Regulation”

1990’s – New Public Management

1995 – Review of Professional Indemnity Arrangements

1999- To Err is Human

“So the fundamental paradigm shift required is for the public sector to become less a ‘doer’ and more a ‘facilitator’, harnessing the resources of the non-government sectors to undertake the actual delivery part of goods and service delivery. “

7/6/2018(McTaggart D and O'Flynn J. (2015) Public Sector Reform. Australian Journal ofPublic Administration 74: 13-22, at p.15)

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System-level interventions and system-level effects

How does the system of health care learn about the health status and needs of populations? What are methods of knowing and

learning?

Federalism

Australian Institute of Health and Welfare – knowledge about the health of populations and the “population” of Australia?

How does the “system” respond to the needs of populations? How do specific stakeholders in

particular building blocks (Governance) orient themselves to the needs of populations/communities?

Financing, delivery, workforce oriented to these needs, e.g., epidemiological communities

Health Care Homes (“coordinate comprehensive care for enrolled patients with chronic and complex conditions.”)

7/6/2018de Savigny D and Adam T. (2009) Systems Thinking for Health Systems Strengthening. In: Alliance for Health Policy and SystemsResearch and World Health Organization (eds). Geneva, Switzerland: World Health Organization, at p.31.

11Populations

Learning about populations and population healthThe role of the professions

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Health care professionals and population health

“When Labor’s health benefits schemes were first announced in 1945, John Cumpston, the Director General of the Commonwealth Department of Health, had warned that programs primarily concerned with paying the doctor were a type of ‘take away medicine’, focusing on paying the doctor for the individual episode of medical care. He argued for a thoroughgoing transformation of the manner in which services were organised, advocating a national system of integrated preventive and curative care, led by salaried doctors trained in the principles of public health and social medicine, not the individualism of fee-for-service.”

7/6/2018Boxall A-m and Gillespie JA. (2013) Making Medicare: The Politics of Universal Health Care in Australia, Sydney, NSW: UNSW Press, p.177

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Philanthropy & entrepreneurial

medicine Not responsive to other "populations”

or communities

Responsiveness and accountability

Doctor

Applies knowledge and works with patient to see what is possible

Patient

Care is a combination of working with

patients as members of (epidemiological)

populations and collectives, families and communities.

⌦ The Community Health Program –integrated health care, introduced by the Labor Government 1975-76. This program drew inspiration from the U.S.

⌦ Neighborhood Health Centers –United States part of the Great Society Program

⌦ From 2 centers in 1964 to 50 by 1968

⌦ Holistic approach to health -integrating health care services with broader community development efforts

⌦ Community voice in governance

⌦ Opposed by AMA and defunded by the Nixon Administration

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Mol A. (2008) The Logic of Care: Health and the problem of patient choice, London and New York: Routledge, Chapter 5

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The characterisation of the “population” is connected with recognition of “communities,” it is responsive to the “task at hand” as doctors and systems of health care care for patients.

Care

Cuba – A system that is responsive to ”populations” and neighborhoods via a Family Medicine Program

Family Medicine Program Physician/Nurse – 800-1,500 people

“In effect, the principles of public health and clinical medicine were combined into a single professional duo emphasizing prevention and epidemiologic analysis with improvement of individual and population health outcomes as the central purpose.”

Neighborhood Health Diagnosis establishes priorities and is a source of information that is fed into the Polyclinic

Supervised by Basic Work Teams in Polyclinics

That receives feedback from Neighborhood organisations.

Polyclinics serve between 20,000-60,000 people, and are hubs that support the Family Medicine Program

Include a range of services and are responsive to the needs and information generated by the Family Medicine Program

⌦ Health care expenditure: 11.1% of GDP

⌦ Life Expectancy: 79 (U.S. figure 79; Aust: 80.1)

⌦ Under 5 mortality: 6 per 1,000 live births (U.S. figure of 2012: 7; Aust: 4.0)

⌦ Infant mortality (2010): 4.2 per 1,000 live births (U.S. figure for 2009: 6; Aust: 3.1)

⌦ Maternal Mortality: 32 per 100,000 live births (U.S. figure for 2012: 28, Aust: 6).

7/6/2018Keck CW and Reed GA. (2012) The Curious Case of Cuba. American Journal of Public Health 102: e13-e22.

World Health Organisation, Pan-American Health Organisation,

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“Populations” and communities

Health care professionals

Patients

Organization and quality improvement – central role of health care professionals – the capacity to pull into the relationship with the patient resources to support care, and

Responsiveness and accountability to “populations”:

Not to “epidemiological communities,

Communities in “place”

Accountable

Not just in quality measures, e.g., responses to Sepsis

Learning about patterns of disease in particular communities

Encouraging learning with communities and being accountable to those communities

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