Tuesday, April 10, 2012

What experience teaches


I have been chair of the board of the Western Sydney Local Health District (WSLHD) for twelve months.  As part of the agreements struck between the Commonwealth and the states and territories, NSW’s large area health services were split into 17 much smaller entities.
These networks or districts are based on public hospital services and their community outreach programs and community health services more generally. They are responsible for a goodly portion of preventive and health promotion services and mental health.
Giving clinicians a stronger voice in the running of the services was a central plank of the new structure as was a clearer consumer voice and connection to the new Medicare Locals.
WSLHD is one of these new entities encompassing a population of about 800,00o people living in Blacktown, Parramatta, Auburn, Mt Druitt and related suburbs, including about 10,000 people who identify as Indigenous.
The board’s brief is to assist in the development of policies and strategies to guide the work of the LHD, to co-operate with the minister and the Ministry of Health, and the related Medicare Local and private agencies to help the district achieve the best levels of health possible. This cannot be done by the health system alone, quite obviously, and we are expected to hear what the community has to say and to relate to other agencies and local government in the pursuit of common goals.
I was asked to write about what I have learned as a result of that year in the chair.
First, I have learned the solid truth behind the aphorism, “The board governs but does not manage.  The managers manage, but do not govern.”  When as a board member of another agency I dabbled in management previously, I made a major error, and nothing in the past year has diminished my acceptance of the wisdom of that division of labour.
The second thing I have learned, or relearned, is that the public health system is populated with people of strong humane concern and altruism. When fire struck a nursing home in western Sydney, off-duty staff from Blacktown Hospital phoned in to see if they could help the hospital cope with the load. I am constantly regaled with stories of people throughout the organisation (and there are thousands of them) doing more than they are asked, connecting to patients and families.
The third thing I have learned is that there is a lot of ‘in spite of’ high quality care. In spite of not engaging in best practice health IT support, financial management systems, and building design, an amazing amount of good work gets done. Somehow we muddle through.
It was Andrew Podger, an outstanding secretary of the Commonwealth health department, who introduced me to the management literature on ‘muddling through’ (See George Maddox 1971 paper in Medical Care Vol 9 No.5  Muddling Through: Planning for Health Care in England).
Muddling isn’t as bad as it may first appear and in fact may be the only way through a contentious, politicised health care problem.
The fourth thing I have had reinforced is the importance of starting where staff – clinical, managerial and support – are in their personal career development.  If we set a goal for more coordinated care in hospitals, or activity-based funding, or patient-centredness in our transactions, then the managers will need to manage that with clinicians and others who are in the thick of service delivery.  If there is to be change, then that change needs careful and often sensitive management.
Fifth, I have learned again just how expensive organisational restructuring is. To make it worthwhile you have to be very clear about what you are trying to achieve, and that the likely benefits outweigh the estimated costs.
Don Berwick, in his birthday advice to the UK NHS, offered ten rules to assure its future health, one of which was ‘Do not restructure.’ His advice was a little more nuanced than the heading, but he recognised the cost.
In this case I do think the restructure into more workable entities was desirable, especially if they change the participation of clinicians and the community.  They also reduce the size of the administrative unity to one that is big enough for a full spectrum of hospital services to be sustained, but not so big that people completely lose touch with one another in the organisation.
The health ministry has coped with stupendous changes with admirable calm and professionalism. Our board itself is a band of splendid people that I am enjoying getting to know.
I do find the work emotionally stressful – the sheer scope of the enterprise is daunting.  I have not had the experience of working in an organisation as complex and huge as this before.  I find my control-freakery and pushiness for practical results needs to be tempered.
In addition, the clinician in me frequently gets upset when I see conditions that do not give patients the best chance of dignified care or optimal outcome. This is one reason why doctors generally do not make good managers – and I guess do not make great board chairs, either.
After one year I find myself wondering whether we have really turned our attention to the big picture quite enough, whether we have done the hard yards of sorting through with managers, clinicians and community where we think it reasonable to expect the LHD to be in five or ten years, delivering what services, to whom, and how? Are we thinking innovatively enough about new models of care?
So we have lots left to do and I feel very privileged indeed to be in the position of chair and to be working with the thousands of dedicated staff in our LHD.

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